RACGP aged care clinical

guide (Silver Book)

5th edition
Part A. Multimorbidity

General principles
• Defining multimorbidity for clinical care purposes requires a pragmatic definition based on patients’ needs.
• Multimorbidity is associated with negative clinical outcomes and patient experience outcomes, and
increased use of healthcare.
• Most clinical trials do not take into account patients with multimorbidity.
• A structured approach to multimorbidity includes identification, establishing treatment burden and jointly
clarifying goals of care.

Practice points
Practice points References Grade
Conduct a comprehensive search of the patient’s electronic medical 10 Consensus-based
records to identify if they have multimorbidity recommendation
Opportunistically screen for multimorbidity during consultations 11 Consensus-based
using tools such as The Instrument for Patient Capacity recommendation
Assessment (ICAN)
Use validated tools to: 13 Consensus-based
• measure the increased risk of hospital admission recommendation

• assess frailty

Establish disease and treatment burden using a framework for 13 Consensus-based

identifying multimorbidity burden recommendation
2 RACGP aged care clinical guide (Silver Book) Part A. Multimorbidity

Introduction
There are multiple definitions of multimorbidity used for different purposes, some of which are presented in Box 1. The
UK’s National Institute for Health and Care Excellence (NICE) encountered the problem of multiple multimorbidity
definitions during the development of their guidelines. 1 As such, NICE took a pragmatic approach, and targeted their
guidelines towards people with multiple conditions that present significant problems to everyday functioning, or where the
management of their care has become burdensome to the patient and/or involves a number of services working in an
uncoordinated way. Using this definition, the problems faced by patients may be due to the severity or nature of their
conditions, but commonly relate to the organisation of the healthcare system and their interaction with it.
For people residing in residential aged care facilities (RACFs), the pragmatic approach taken by the NICE guidelines is of
appeal, thus the same approach has been adopted in the RACGP aged care clinical guide (Silver Book).

It is important to recognise that some sub-populations of older people, including Aboriginal and Torres Strait Islander
peoples, veterans, and culturally and linguistically diverse peoples, experience differences in multimorbidity prevalence.

Box 1. Definitions of multimorbidity

Multimorbidity is commonly defined as the presence of two or more chronic medical conditions in an individual, and
can present several challenges in healthcare, particularly with higher numbers of coexisting conditions and related
polypharmacy. 2

Complex multimorbidity is defined as ‘co-occurrence of three or more chronic conditions affecting three or more
body systems within one person, without defining an index condition’. 3

Other definitions are broader and include any combination of chronic disease with at least one other disease (acute
or chronic) or biopsychosocial factor (associated or not) or somatic risk. Any biopsychosocial factor, any somatic risk
factor, the social network, the burden of diseases, the health consumption, and the patient’s coping strategies may
function as modifiers of the effects of multimorbidity. Multimorbidity may modify the health outcomes and lead to an
increased disability or a decreased quality of life or frailty. 4
The role of diseases, risk factors, symptoms and severity need to be included in the definition. 5

Clinical context
Multimorbidity is common, and most research uses the parameter of ‘two or more chronic medical conditions’ as the
definition for multimorbidity. The prevalence of multimorbidity is reported to be in the order of 25%, and the prevalence
has been found to increase with:

• increasing age (Figure 1)

• socioeconomic deprivation
• the female gender.
As physical conditions increase, the likelihood of a mental health condition increases (refer to Part A. Mental health).
 RACGP aged care clinical guide (Silver Book) Part A. Multimorbidity 3

Figure 1. Prevalence of multimorbidity versus age 6

Reproduced with permission from Salisbury C, Johnson L, Purdy S, Valderas JM, Montgomery AA. Epidemiology and impact of multimorbidity in
primary care: A retrospective cohort study. Br J Gen Pract 2011;61(582):e12–21.

The prevalence of multimorbidity varies based on the definition. If multimorbidity is defined by the number of: 7

• medical conditions
– 25.7% of the general population had two or more diagnosed chronic conditions
– 15.8% of the general population had three or more diagnosed chronic conditions
• body systems affected by these chronic conditions
– 23.0% of the general population had two or more body systems affected by chronic conditions
• complex multimorbidity (as noted in Box 1)
– 12.1% of the general population had complex multimorbidity.
In a large Australian study of older people, 82% of respondents reported having at least one chronic disease, and more
than 52% reported having at least two chronic diseases. 8 Respondents experiencing any chronic diseases had an
average of 2.4 comorbid diseases. Three defined groups of chronic diseases were identified as:

• asthma, bronchitis, arthritis, osteoporosis and depression

• high blood pressure and diabetes
• cancer.
In addition, heart disease and stroke were classed in a separate group, or have ‘attached’ themselves to different groups
in different analyses.
The authors of the study concluded that ‘the consistency of the findings suggests there is co-occurrence of diseases
beyond chance, and patterns of co-occurrence’.8

Issues associated with multimorbidity

People who have multimorbidity are found to experience: 9

• reduced quality of life

• higher mortality
• polypharmacy
• higher treatment burden
4 RACGP aged care clinical guide (Silver Book) Part A. Multimorbidity

• greater likelihood of uncoordinated and fragmented care

• vulnerability to safety issues due to poor health, advanced age, cognitive impairment, limited health literacy and
comorbidity of depression or anxiety
• greater use of services
– higher consultation rates with healthcare professionals and general practitioners (GPs)
– higher number of hospital admissions.

In practice
The World Health Organization (WHO) surmised that:9
Clinical guidelines review and summarise evidence about the most effective treatments for specific conditions
and provide recommendations for their use. However, guidelines are almost always focused on single
conditions. For instance, among others, there are individual guidelines for diabetes, asthma and stroke.
Guidelines rarely take into account multimorbidity. The randomised trials on which guidelines are based very
often exclude people with multiple conditions from taking part. The socioeconomic characteristics of participants
in the trials are rarely reported, making it difficult for primary care providers to use the evidence for their diverse
patient case mix. The potential for interactions between medications and between conditions makes the
application of single disease-based clinical guidelines potentially hazardous for people with multiple conditions.

This raises the need for a set of guiding principles to support practitioners in the identification, assessment and
management of patients with multimorbidity.1 The guiding principles need to take into account:

• an awareness of multimorbidity and the broad clustering of conditions, including

– physical health conditions
– mental health conditions
– ongoing conditions
– symptom complexes (eg chronic non-malignant pain, frailty)
– sensory impairment
– alcohol and drug disorders
• the concept that treatment options for the range of conditions a person may have will be based on single
disease/condition guidelines, which will most likely be drawn from research on people without multimorbidity. This
may also lead to conflicting opinions from different specialists
• that management of additional risk factors for future disease can place unnecessary burden on people with
multimorbidity
• that there is a need for a genuine patient-centred approach, including
– a discussion about how the person’s health conditions and their treatments interact and affect quality of life
– a discussion about their goals, preferences and priorities for care
– a discussion about the benefits and risks of treatments (not researched in a group with multimorbidity)
– identifying opportunities for improving coordination and integration of care for the individual
– minimising treatment burden to improve quality and safety.

Identification of multimorbidity
As with a systematic approach to care for any chronic disease, it is helpful to identify the group of patients who will
benefit most from a multimorbidity approach. For those living in RACFs, this may include the majority of residents.
Nevertheless, explicit identification is an important first principle to delivering systematic care. Given the multiple
contributors to multimorbidity, the identification of patients with multimorbidity needs to take a multi-faceted approach.
The approach should be based on: 10

• a search of the patient’s past records, including electronic medical records

 RACGP aged care clinical guide (Silver Book) Part A. Multimorbidity 5

• identifying patients who have hyper-polypharmacy (defined as 15 or more medications). Patients on fewer than 15
medications but at high risk of adverse events may also benefit from management using a multimorbidity approach
(refer to Part A. Polypharmacy)
• the use of validated tools – recommendations include
– tools to measure the increase in risk of hospital admission – there are a large number of such tools that have
been reviewed by the NSW Agency for Clinical Innovation. 11 The lack of integration with electronic medical
systems and integrated datasets may limit the ability to use them optimally
– tools to assess frailty (refer to Part A. Frailty)
• opportunistically screening during consultations. Using a tool such as The Instrument for Patient Capacity
Assessment (ICAN) 12 ‘shifts the focus from the medical condition of the person to their situation in life, identifies what
the person values doing and being, explores how healthcare and other resources serve or limit this person, and
recognises and cultivates opportunities to advance the person and their situation’. 13 For clinicians, this tool
recommends asking three questions
– What are you doing when you are not sitting here with me?
– Where do you find the most joy in your life?
– What's on your mind today?

Approaches to multimorbidity
Figure 2 illustrates the approach to managing multimorbidity.

Figure 2. Approach to multimorbidity management

Discuss the purpose of an approach to care that takes into account multimorbidity

Establish disease and treatment burden

Establish patient goals, values and priorities

Review medicines and other treatments considering individual risk:benefit ratio

Agree on an individualised management plan with the person

Purpose of approach to care

Discuss with the patient, their carers and/or alternative decision makers that the purpose of a multimorbidity approach
(and the aim of healthcare in general) is to improve the quality of life. Quality of life with multimorbidity may be improved
by reducing treatment burden and optimising care by identifying:13

• ways of maximising benefit of existing treatment (eg identifying those at high risk when using osteoporosis
medication to manage risks of fracture)
• treatments with limited benefit that may be stopped (eg herbal therapies)
• treatment and follow-up plans with high burden (eg routine follow up with specialists)
• medicines with higher risk of adverse events (eg warfarin and novel oral anticoagulants [NOACs] in a person with a
high risk of falls)
• alternative arrangements for follow-up appointments to coordinate care or optimise appointments (eg home visits,
community healthcare nursing support, remote pacemaker assessments or telehealth).

Establish burden of illness and treatment

As a minimum, GPs could consider: 14

• healthcare tasks being imposed on the patient and/or their carers/family

• factors (eg personal, social, financial) that could exacerbate the burden of treatment in this patient
6 RACGP aged care clinical guide (Silver Book) Part A. Multimorbidity

• consequences of the healthcare tasks imposed on this patient.

Table 1 offers a framework to assist in identifying the burden experienced by the patient. 15 Given the high prevalence of
mental health with increasing physical conditions, patients should also be screened for anxiety and depression, and GPs
should also be alert for chronic pain concerns (refer to Part A. Pain and Part A. Mental health).

Table 1. Framework for identifying multimorbidity burden

Reproduced with permission from Trevena L. Minimally disruptive medicine for patients with complex multimorbidity. Aust J Gen Pract
2018;47(4):175–79. Available at www1.racgp.org.au/ajgp/2018/april/minimally-disruptive-medicine [Accessed 7 August 2019].
 RACGP aged care clinical guide (Silver Book) Part A. Multimorbidity 7

Establish patient goals, values and priorities

Build on previous conversations, such as those using the ICAN tool, to encourage and explore with patients (or their
carers/families and alternative decision makers) the things that are important to them. The aim of managing
multimorbidity is to individualise care based on the patient’s personal preferences; therefore, establishing their values,
goals and priorities are critical to managing multimorbidity. This should include a discussion about longevity, quality of
life, and treatment burden, and an exploration of the person’s attitudes to their treatments and the potential benefits and
harms of those treatments.

Reviewing medicines and other treatments

When reviewing medications and treatments, it is important to consider the effectiveness of treatment/s, the duration of
treatment trials and the populations in the trial.
The Silver Book Part A chapters on Polypharmacy and Deprescribing provide an overview of the approach to managing
polypharmacy and identifying opportunities to deprescribe. The chapters highlight tools such as the Screening Tool of
Older People’s Prescriptions (STOPP) and Screening Tool to Alert to Right Treatment (START) to not only identify
medication-related safety concerns and potential medication to cease, but also medications that the person currently is
not taking that may offer benefit. The accredited pharmacist plays a critical role in supporting this component.

Individualised management plan

The outcome of the preceding four steps should be an individualised management plan that:12,16

• documents the patient’s goals, values, preferences and priorities

• includes an action plan of medication and treatments that has details of what is being stopped, what is being
changed and what is being started
• details information to support coordination of care and identify who is responsible for coordination of care
• arranges follow-up appointments and review of the care plan, including arrangement for continuity of care, given
increasing evidence that shows a positive correlation between quality of care and continuity of care.
This guidance offers a pragmatic approach to managing multimorbidity. The evidence for best practice to manage
multimorbidity continues to emerge. What is clear is that ‘one size does not fit all’ and the management of patients with
multimorbidity offers a unique opportunity to practice authentic patient-centred care.
8 RACGP aged care clinical guide (Silver Book) Part A. Multimorbidity

References
1. National Institute for Health and Care Excellence. Multimorbidity: Clinical assessment and management. England: NICE, 2016. Available at
www.nice.org.uk/guidance/ng56 [Accessed 7 August 2019].

2. Fortin M, Bravo G, Hudon C, Vanasse A, Lapointe L. Prevalence of multimorbidity among adults seen in family practice. Ann Fam
Med 2005;3:223–28.

3. Harrison C, Henderson J, Miller G, Britt H. The prevalence of complex multimorbidity in Australia. Aust N Z J Public Health 2016;40(3):239–44.

4. Le Reste JY, Nabbe P, Manceau B, et al. The European General Practice Research Network presents a comprehensive definition of
multimorbidity in family medicine and long-term care, following a systematic review of relevant literature. J Am Med Dir Assoc 2013;14:319–25.

5. Willadsen TG, Bebe A, Koster-Rasmussen R, et al. The role of diseases, risk factors and symptoms in the definition of multimorbidity –
A systematic review. Scand J Prim Health Care 2016:1–10.

6. Salisbury C, Johnson L, Purdy S, Valderas JM, Montgomery AA. Epidemiology and impact of multimorbidity in primary care: A retrospective
cohort study. Br J Gen Pract 2011;61(582):e12–21.

7. Harrison C, Henderson J, Miller G, Britt H. The prevalence of diagnosed chronic conditions and multimorbidity in Australia: A method for
estimating population prevalence from general practice patient encounter data. PLoS One 2017;12(3):e0172935.

8. Islam MM, Valderas JM, Yen L, Dawda P, Jowsey T, McRae IS. Multimorbidity and comorbidity of chronic diseases among the senior
Australians: Prevalence and patterns. PLoS One 2014;9(1):e83783.

9. World Health Organization. Multimorbidity: Technical series on safer primary care. Geneva: WHO, 2016.

10. Souri S, Symonds NE, Rouhi A, et al. Identification of validated case definitions for chronic disease using electronic medical records:
A systematic review protocol. Syst Rev 2017;6:38.

11. Agency for Clinical Innovation. Decision support tool: Summary of patient identification and selection tools. Chatswood, NSW: ACI, 2018.
Available at www.aci.health.nsw.gov.au/__data/assets/pdf_file/0008/287441/decision-support-tool-patient-identification.pdf [Accessed
7 August 2019].

12. Boehmer KR, Hargraves IG, Allen SV, Matthews MR, Maher C, Montori VM. Meaningful conversations in living with and treating chronic
conditions: Development of the ICAN discussion aid. BMC Health Serv Res 2016;16:514.

13. Minimally Disruptive Medicine. The Instrument for Patient Capacity Assessment (ICAN). Available at
https://minimallydisruptivemedicine.org/ican [Accessed 7 August 2019].

14. Trevena L. Minimally disruptive medicine for patients with complex multimorbidity. Aust J Gen Pract 2018;47(4):175–79.

15. Tran VT, Barnes C, Montori VM, Falissard B, Ravaud P. Taxonomy of the burden of treatment: A multi-country web-based qualitative study
of patients with chronic conditions. BMC Med 2015;13:115.

16. Barker I, Steenton A, Deeny S. Association between continuity of care in general practice and hospital admissions for ambulatory care
sensitive conditions: Cross-sectional study of routinely collected perswon level data. BMJ 2017;356:j84.
 RACGP aged care clinical
guide (Silver Book)
5th edition
Part A. Palliative and end-of-life care

General principles

• Palliative care is a fundamental component of general practice.

• Most people die from chronic diseases that progress along one of three typical illness trajectories to the end
of life, which are:
– cancer (short decline)
– non-malignant organ failure (intermediate decline with acute episodes)
– frailty, dementia (gradual dwindling).

• Patient care along the illness trajectory can ideally transition smoothly from chronic disease management to
treatment of advanced illness, to a palliative approach, end-of-life care and terminal phase:
– A palliative approach shifts the primary focus from life-prolonging treatments towards symptom treatment
and quality of remaining life.
– End-of-life care is focused on providing increased services and support for the person’s physical,
emotional, social and spiritual/existential issues as they approach death.
– The GP’s role in end-of-life care includes a terminal care plan, care after death and bereavement support
for patients and their families.
– GP self-care and support of colleagues is important to prevent stress, burnout and compassion fatigue.
2 RACGP aged care clinical guide (Silver Book) Part A. Palliative and end-of-life care

Practice points
Practice points References Grade
Initiate advance care planning early when patients have capacity to 28–31, 38 Consensus-based
express their wishes and directives for care if they become too ill or recommendation
cognitively impaired to make decisions
General practitioners (GPs) can use a proactive, systematic – Consensus-based
approach to anticipate and provide person-centred care to the end recommendation
of life and a ‘good death’ by:

• initiating advance care planning early to document patient

wishes and directives

• anticipating and assessing escalating palliative care needs early

along the illness trajectory

• establishing clinical care goals and treatment decisions with the

patient/medical decision maker

• reviewing clinical care plans frequently to address symptoms

and physical, psychosocial and spiritual/existential issues

• coordinating and participating in the provision of team-based

end-of-life care.

Early identification, assessment and management of escalating 13 Consensus-based

palliative care needs are important to relieve symptoms, avoid recommendation
suffering, reduce need for hospital care, and improve quality of
remaining life and the death experience
Recognise escalating palliative care needs at major transition 13 Consensus-based
points along the illness trajectory to initiate timely: recommendation

• palliative approach

• end-of-life care

• terminal care, including after-death and bereavement support

Indicators such as the ‘surprise question’ and the Supportive and 5, 6, 44, 47 Consensus-based
Palliative Care Indicators Tool (SPICT) can help identify patients recommendation
early when considering whether a person may benefit from a
palliative approach
Consider using symptom assessment tools, which can be valuable 34 Consensus-based
in identifying symptoms, scoring their severity and monitoring the recommendation
effectiveness of treatments

Introduction
An Australian man aged 65 years in 2009 could expect to live an average of 8.2 years without disability, and another
10.5 years with disability, including 3.5 years with severe or profound activity limitation. An Australian woman aged
65 years in 2009 could expect to live an average of 9.7 years without disability, and another 12.1 years with disability,
including 5.6 years with severe or profound activity limitation. 1

About two-thirds of Australians die between 75 and 95 years of age.1 In 2005, 54% of people aged >65 years died in
hospital, 32% in residential aged care facilities (RACFs), and 14% elsewhere (eg home). 2
Chronic diseases are responsible for 90% of deaths, 3 and about 70% of deaths are ‘expected’ due to advanced
disease, 4 predominately cardiovascular diseases (eg coronary heart disease, stroke), dementia and Alzheimer’s
disease, chronic respiratory disease and lung cancer.
Death is often preceded by a period of significant disability, interspersed by life-threatening events. Patients with
advanced diseases have an average of eight hospital admissions in their last year of life. 5 Many of these involve
 RACGP aged care clinical guide (Silver Book) Part A. Palliative and end-of-life care 3

treatments that are of little or no benefit, or may cause more harm than benefit, 6 and patients often do not have the
capacity or opportunity to discuss their wishes for care. 7

Clinical context
The current Australian healthcare system does not meet patient preferences for care at the end of life.4 For instance,
the low proportion of people dying at home is at odds with the stated preferred place of death of patients; and is half
that of comparable countries such as New Zealand, the US, Ireland and France.4 Place of death is a key indicator of
quality end-of-life care. 8 Preferred place of death is influenced by many factors, including: 9

• connectedness to community

• family

• availability of services and equipment

• complexity of caregiving and decision making.

Preference for receiving care at home is stronger for end-of-life care during the last months of life than for death at
home. Transfer from home may occur in the last few days due to rapidly escalating patient care needs, patient safety
risks or carer exhaustion.

Principles of a ‘good death’ have been summarised from surveys of people approaching death and their relatives.
Patient priorities for end-of-life care include: 10,11

• knowing when death is coming and what to expect

– reasonable control of what happens
– ensure wishes are respected
– choice to leave when it is time
– avoid prolonging dying

• choice and control over where death occurs

– who is present and who shares the end
– time to say goodbye
– arrange important affairs

• access to
– ‘hospice-style’ quality care in any location
– necessary information and expertise
– control of pain and other symptoms
– dignity and privacy
– spiritual or emotional support

• strengthening of relationships, and relieving burdens placed on the family.

Australia’s healthcare system is facing the challenge of shifting away from a hospital-centric provision of treatment at
the end of life towards better support for people who wish to receive care within their community during their last
months of life.4,12

Palliative care
Palliative care, while originally associated with cancer care, is appropriate for anyone with life-limiting illnesses,
including non-malignant degenerative diseases, and dementia (refer to Part A. Dementia). In the past decade,
palliative care has become available within almost every healthcare setting, including general practices, RACFs,
acute hospitals and generalist community services.12
4 RACGP aged care clinical guide (Silver Book) Part A. Palliative and end-of-life care

Each year in Australia, about 160,000 people die, and around 100,000 of these deaths are predictable. Of those,
40,000 patients receive specialist palliative care and 60,000 do not. Patients may receive palliative care for years,
months, weeks or days before death.1
People receiving palliative care have fewer episodes of hospitalisation, shorter lengths of stay when they are
hospitalised, and reduced visits to emergency departments. Those who receive palliative care at home have been
shown to have increased quality of life and reduced need for hospital-based care.12
Box 1 provides definitions of palliative care; there is no clear demarcation point between curative and palliative intent,
or at the transition between phases of palliative care.

Box 1. Definition of phases of palliative care

Palliative care:

• World Health Organization – Palliative care is an approach that improves the quality of life of patients and their
families facing the problems associated with life-threatening illness, through the prevention and relief of suffering
by means of early identification and impeccable assessment and treatment of pain and other problems –
physical, psychosocial and spiritual. 13

• Palliative Care Australia – Palliative care is person-centred and family-centred care provided for a person with an
active, progressive, advanced disease, who has little or no prospect of cure and who is expected to die, and for
whom the primary goal is to optimise the quality of life. 14
Palliative approach:

• A palliative approach recognises that death is inevitable and focuses on the care rather than cure of a person
with multiple chronic conditions, frailty and/or a life-threatening or life-limiting illness. The goal of a palliative
approach is to improve or optimise a person’s level of comfort and function and to offer appropriate treatment for
any distressing symptoms. A palliative approach addresses a person’s psychological, spiritual, social, emotional
and cultural needs. Families are welcomed as partners in this approach. A palliative approach recognises that for
older people with multiple chronic conditions, frailty and/or a life-threatening or life-limiting illness, that this is
often the last chapter of their life, the length of which is unknown. 15
End-of-life care (and terminal phase):

• End-of-life care is the last few weeks of life in which a patient with a life-limiting illness is rapidly approaching
death. The needs of patients and carers are higher at this time.
– This phase of palliative care is recognised as one in which increased services and support are essential to
ensure quality, coordinated care from the healthcare team is delivered.
– This takes into account the terminal phase or when the patient is recognised as imminently dying, death and
extends to bereavement care.14

For definitions and up-to-date information on legal issues that can arise with palliative medicine (eg double jeopardy)
and end-of-life decision making, refer to End of Life Law in Australia.
At the time of writing, euthanasia is illegal in all Australian states and territories. Since 19 June 2019, voluntary
assisted dying (VAD) became legal in Victoria and is being considered in other states. VAD involves administering a
medication for the purpose of causing death in accordance with the steps and processes set out through legislation.
VAD must be voluntary, and will usually be self-administered by the individual.
In Victoria, the Voluntary Assisted Dying Act 2017 (Vic) (the Act) sets legal criteria for an individual to be eligible for
VAD, for health practitioners to be involved with VAD, and for the VAD processes overall. The Act provides for, and
regulates, access to VAD, defined as ‘the administration of a voluntary assisted dying substance, and includes steps
reasonably related to such administration’. 16 Health practitioners can conscientiously object to being involved with
VAD, and in Victoria, cannot raise the issue of voluntary assisted dying with patients (even indirectly).

The process for an individual to request and access VAD is separate from, and cannot be included in, advance care
planning or palliative care. Once a person requests information about VAD, knowledge of best practice for end-of-life
discussions is an important part of communicating about VAD. A patient receiving palliative care, if eligible, can
concurrently request and have access to VAD through a separate pathway.
Further information on Victoria’s VAD is available on the Department of Health and Human Services website.
 RACGP aged care clinical guide (Silver Book) Part A. Palliative and end-of-life care 5

The National Palliative Care Strategy (the Strategy) highlights a focus on ‘living well with chronic illness’ and
maximising quality of life, and six guiding principles:12

• Palliative care is person-centred care

• Death is a part of life

• Carers are valued and receive the care they need

• Care is accessible

• Everyone has a role to play in palliative care

• Care is high quality and evidence based

Specialist palliative care services usually include doctors, nurses, physiotherapists, occupational therapists, social
workers, clinical pharmacists, dietitians, speech therapists and pastoral care workers. Specialist palliative care
services may be available to support general practitioners (GPs) and patients by providing help with: 18

• complex problems, symptom control, admission to hospice or hospital

• advice on ethical dilemmas (eg nutrition, hydration)

• spiritual issues, concerns held by the patient or carers, sense of therapeutic partnership

• resources for bereavement management.

The Strategy recognises that GPs play an essential role in advance care planning and providing palliative care for
patients with terminal illnesses living in the community and RACFs.12

GPs’ role at the end of life

As patients approach the end of life, the GP’s role is to apply the principles and approach to care of older people
presented throughout this Silver Book. There is a sharper focus on:

• person-centred care to support wellbeing and quality of remaining life, and to respect the person’s values, goals
and treatment choices

• proactive clinical care planning to anticipate and provide care as the person’s clinical condition deteriorates, and
as goals of care shift from treating illness towards comfort and managing death.
All GPs who care for older people are engaging with issues their patients face towards the end of life. Even small
shifts in emphasis towards anticipating and planning to minimise the effect of predictable problems can improve the
care offered, and the quality of life experienced by patients and carers. For example, a high-quality handover to the
GP who will care for the patient on admission to an RACF can enhance continuity of care and future care planning.

Rural GPs can often continue providing care for patients as they move between home, RACFs or rural hospitals.
They may also be required to fill in for lack of patient access to community nursing, specialist palliative care services
and equipment for home care.
Chronic disease prevention and management are already established as major routine parts of general practice. The
rationale is compelling for GPs to extend management of progressive chronic diseases to meet patients’ needs for
community-based end-of-life care and a ‘good’ death.
The number of patients seeking GP care at the end of life is increasing because of multiple interacting factors,
including:

• an ageing population

• technological advances that prevent premature death and extend life

• a growing number of general practice patients with progressive chronic life-limiting diseases, and associated
disability and cognitive impairment

• patients seeking to avoid medical and hospital treatments that are of limited benefit and not wanted at the end of
life

• a greater proportion of the population selecting palliative care at home or in RACFs

• the current gaps in services for end-of-life care in the community (ie inequality of access and service provision,
lack of integration and communication between services)
6 RACGP aged care clinical guide (Silver Book) Part A. Palliative and end-of-life care

• increased patient awareness of advance care planning for voicing their preferences for end-of-life care and place
of death.
GPs have many of the skills required to provide advanced disease management and palliative care through to the
end of life. These include:

• systematic chronic disease management

• person-centred care and communication

• shared decision making and goals of care

• supporting carers and family

• dealing with uncertainty

• anticipating likely events

• clinical care planning, including crisis planning

• team care participation and coordination

• using tools and resources to supplement knowledge and skills

• referrals and shared care with specialists and local team-based support services

• use of peer support and training.

However, GPs have reported that a major barrier to providing advance care planning and palliative care is their
uncertainty and lack of knowledge about prognosis, illness trajectory and terminal phase of advanced chronic
diseases 19,20 (eg cancer, 21 heart failure,21 dementia).21,22
GP awareness of illness trajectories allows anticipation of likely events and practical planning for end-of-life care. 23

In practice
Anticipating patient needs
The key to GP care of patients through to the end of life is a proactive systematic approach based on anticipating
patient clinical needs and care preferences. Three important concepts have been developed, which can help
clinicians anticipate, discuss and plan clinical care to meet patient needs, and also help patients and carers
understand and cope with their situation: 24,25

• Typical illness trajectories for chronic conditions

• Advance care planning

• Early identification of palliative care needs

Illness trajectories
Three typical illness trajectories have been described for people with progressive chronic illness, which are:23

• cancer (short decline)

• organ failure (intermediate with acute episodes)

• frailty or dementia trajectory (gradual dwindling).

Patients with specific progressive chronic diseases often have common patterns of experiences, symptoms and
palliative care needs.

Figure 1 illustrates the typical illness trajectories for chronic conditions,23 juxtaposed with the phases of palliative care
towards the end of life.
 RACGP aged care clinical guide (Silver Book) Part A. Palliative and end-of-life care 7

Figure 1. Typical illness trajectories and palliative care phases towards the end of life

Trajectory 1 – Cancer (short decline)

In trajectory 1 (typically cancer), there is steady progression with a slight decline in physical health over months to
years with periods of positive or negative effects of cancer treatment. This is followed by a short period of evident
decline with a clear end-of-life phase of increasing symptoms and rapid decline in weight and functional status in the
last weeks or months of life.

Trajectory 2 – Organ failure (intermediate with acute episodes)

Trajectory 2 typically occurs in non-malignant, life-limiting illness with organ failure (eg advanced heart disease, lung
disease). There is an intermediate rate of decline in function over years with long-term limitations and acute, often
life-threatening exacerbations and hospital treatment, followed by further deterioration. Death often seems ‘sudden’
and may occur at any time along the trajectory, with symptoms of end-stage organ failure.

Trajectory 3 – Frailty or dementia (gradual dwindling)

Trajectory 3 is a gradual dwindling decline of physical and/or cognitive function, which typically occurs in frailty or
dementia. People with dementia have a long, variable disease course up to six to eight years prior, early impairment
of memory and reduced capacity for decision making and communication (refer to Part A. Dementia). People with
frailty, a syndrome of general physiological decline that occurs in later life, often lack a specific disease diagnosis
(refer to Part A. Frailty). The last year of life is characterised by a steady slow decline in overall function, rather than a
sudden decline in any one domain. Frailty and dementia together predict a more rapid decline.

Each of the three illness trajectories has physical and associated psychological, social, and spiritual/existential
domains.23
Multimorbidity, polypharmacy and the patient’s wishes and directives also have the potential of altering the patient’s
illness trajectory and should be considered when planning clinical care.
Discussion of the likely disease trajectory at the time of advance care planning and clinical care planning can help
patients and carers:23,24

• clarify the person’s goals of care and treatment preferences

• improve quality of life and symptom control

• reduce distress
8 RACGP aged care clinical guide (Silver Book) Part A. Palliative and end-of-life care

• plan for a good death, including preferred place of death

• avoid unwanted hospital admission

• contribute to informed decision making and care delivery (whether at home, RACF or hospital).

Advance care planning

Advance care planning is an essential tool for end-of-life care that is person centred. It is a process where a person
discusses their values and healthcare preferences with their family, friends and healthcare team. Ideally, advance
care planning will result in a formal, written advance care directive (addressing values and/or instructions) to help
ensure the person’s preferences are respected. As a part of their advance care directive, a person can choose a
‘medical decision maker’, who would make decisions for the person if they were not able to communicate. 26
Advance care plans have been shown to:

• improve patients’ quality of end-of-life care 27,28 and death experience

• improve adherence to patients’ wishes 29

• improve patient and family satisfaction with care29,30

• initiate earlier provision of palliative care 31 with prolonged survival 32

• increase chance of dying in place of choice (eg RACF with palliative care, rather than death in hospital) 33

• reduce hospital length of stay for people aged >65 years admitted from an RACF 34

• promote communication, make palliative care easier and more efficient, and reduce distrust and conflict between
family, friends and healthcare practitioners. 35

When to initiate advance care planning

Given their longstanding, trusted relationships with patients, GPs are well placed to initiate and implement an
advance care plan.33 An advance care planning conversation fits well with giving advice on healthcare options for any
current diagnosis and realistic assessment of prognosis. 36
Many patients will have limited or no capacity to communicate their preferences and make decisions personally when
their health deteriorates at some points along their illness trajectory. For example, this may occur:

• when ill during cancer treatment or near the end of life on trajectory 1

• when suffering an acute life-threatening illness or advanced organ failure on trajectory 2

• early in dementia on trajectory 3.

Advance care planning is ideally discussed early, when patients are well and have capacity to anticipate, discuss and
plan for preferred treatment when they become too ill or cognitively impaired to express their wishes.

Initiating advance care planning and documentation of an advance care directive is recommended routinely in the
75+ health assessment, progressive chronic disease management, early dementia or frailty, or at entry into RACFs.
Forms and requirements for advance care plans vary between states and territories. Resources are available for
competent adults and those who lack decision-making capacity to undertake advance care planning. Further
information and forms for each state or territory can be found at Advance Care Planning Australia. 37
 RACGP aged care clinical guide (Silver Book) Part A. Palliative and end-of-life care 9

Assessment of decision-making capacity

A person is assumed to have decision-making capacity unless there is evidence to indicate otherwise. Competence
or lack of competence can fluctuate over time and for different levels of decision making, and is specific to the issues,
actions or decisions at hand. People should always be involved in decisions that concern them to the maximum
extent possible.37 Refer to Advance Care Planning Australia for more information.
Assessment of capacity should take place as close as possible to the time the decision is required. A person with
capacity should:37

• know the decision facing them

• know the possible options

• know the reasonably foreseeable outcomes of the options available

• be able to provide a rationale for decisions they have made and therefore demonstrate ability to consider the
information, balance the risks and make a choice.
If a person lacks capacity to make medical treatment decisions themselves, there are three ways in which decisions
can be made by, or for them:25

• An advance care directive made by the person before they lose capacity can provide directions about medical
treatment.

• A substitute decision maker can make the decision, based on what they believe the person would want and their
best interests.

• A tribunal or the courts can provide consent or make a treatment decision.

Person-centred care

Dying is a multidimensional experience with physical, psychological, social, and spiritual or existential aspects. 38
Each patient has a unique life journey, with their own combination of personal character and strengths, relationships
with others, cultural background, values, work and life experiences, and physical and mental health comorbidities.
GPs provide medical care throughout life to a diverse range of people, and are therefore well placed to understand
patients’ views of their situation and expectations, and to be responsive to the personal influences of cultural and life
experiences.
Box 2 illustrates factors to consider when providing end-of-life care for people from diverse backgrounds.12,39

Box 2. Personal factors to consider when providing end-of-life care to patients from diverse backgrounds

Cultural differences:
A patient’s beliefs, values and traditional healthcare practices are relevant at the end of life for them and their
families. Other cultural considerations include:

• communication issues

• modes of decision making

• role of advance care planning

• concepts of disease, death and dying in relation to the rest of life

• customs surrounding death, burial or cremation and bereavement

• meaning of pain and other symptoms

• attitudes to medication and nutrition

• privacy issues

• spiritual and religious issues and rituals.

Aboriginal and Torres Strait Islander peoples: When caring for Aboriginal and Torres Strait Islander people, it is
important to work in partnership with Aboriginal health workers and carers, and be sensitive to the cultural and
spiritual meaning of dying, death and place of death, and the effect of earlier experiences of loss and historical
shared community heritage of loss. 40
10 RACGP aged care clinical guide (Silver Book) Part A. Palliative and end-of-life care

Lesbian, gay, bisexual, transgender, intersex (LGBTI) people: Be aware that many LGBTI people may have
experienced prejudice and discrimination in healthcare settings. Care for the person at the end of life includes
respect and support of their self-designated family, substitute decision maker and chosen carer/s.
People with severe mental health conditions: People with severe mental health conditions may have had
delayed diagnosis and care of their life-limiting illness, and poorly met social, housing, income and support needs.
Consider extra support from mental health services.

Early identification of palliative care needs

Awareness of illness trajectories enables early identification of needs and practical planning for palliative care.
Figure 1 illustrates the phases of palliative care juxtaposed with typical illness trajectories for chronic conditions.
Three major transition points can occur along the illness trajectory and if recognised, can enable better palliative
care:

• Early identification of palliative care needs and initiation of a palliative approach

• Reassessment of palliative care needs and initiation of end-of-life care plan

• Identifying dying and initiation of terminal care plan, planning for after-death care and bereavement support
GPs caring for patients with a life-limiting illness can consider, discuss and agree on a palliative approach at any
point on their illness trajectory. Early palliative care may prolong life for patients, and improve quality of life for
patients and carers, by promoting realistic medicine and preventing ineffective burdensome treatment.38
Early palliative care needs are different for people with different conditions. The three illness trajectories and their
physical, psychological, social and spiritual/existential domains can be applied in early palliative care planning to
prevent distress, as shown in the four-minute video Palliative care from diagnosis to death, and are outlined below: 41

• Trajectory 1 – Social decline may occur at the same time as physical decline. However, people with cancer may
need an early palliative approach even when they are physically well to acknowledge psychological symptoms
(eg anxiety) and spiritual or existential distress and questioning that may peak at diagnosis, hospital discharge or
cancer recurrence, as well as during the physical decline and terminal phase.

• Trajectory 2 – Social and psychological decline often run in parallel with physical decline and life-threatening
exacerbations followed by partial recovery. Emotional and spiritual or existential distress may increase steadily in
people with organ failure because of a loss of physical capacity and independence. An early palliative approach
that addresses psychological and social issues and physical aspects may be more effective in preventing
distress.

• Trajectory 3 – For people with frailty or dementia, gradual physical and cognitive decline may cause parallel loss
in activities of daily living with early social withdrawal, emotional and spiritual or existential distress (refer to
Part A. Frailty; refer to Part A. Dementia). An early palliative approach can:
– support physical health as well as enable social and psychological resilience and a sense of purpose
– address anxiety and fears of loss of independence, dementia or becoming a burden.

Indicators of foreseeable decline towards death

End-of-life processes are multifactorial, so each person’s prognosis will imply a degree of uncertainty. Patients may
follow none or several of the three trajectories, progress at different rates and die at any point.23
Many people, particularly if they have organ failure or multimorbidity, are identified too late to benefit from a palliative
approach that is integrated with appropriate treatment of their underlying illnesses.
An important step in early recognition of patients with palliative care needs is anticipating and looking for foreseeable
deterioration to death. GPs can then plan care as soon as it might be of benefit, rather than only in the last few weeks
or days of life.
Indicators that a person might be nearing the end of life include:18

• answering ‘no’ to the ‘surprise question’ – ‘Would I be surprised if this patient were to die in the next few months,
weeks, or days?’ 42

• general features of decline including deterioration in health status, increasing need, or choice for no further active
life-prolonging treatments
 RACGP aged care clinical guide (Silver Book) Part A. Palliative and end-of-life care 11

• specific clinical indicators related to disease progression

• the use of tools such as the Supportive and Palliative Care Indicators Tool (SPICT) to identify people whose
health is deteriorating 43

• considering what can realistically be achieved for the patient.

The ‘surprise question’ is intended to be used to consider death in the foreseeable future and help identify patients
who might benefit from a palliative approach.
General factors are more reliable end-of-life prognostic indicators than disease-centred variables, particularly for
older patients with multiple chronic conditions. General factors include:23,24

• functional, nutritional and cognitive impairment (eg weight, mobility, activities of daily living, communication,
interactions)

• emotional problems

• geriatric syndromes (eg delirium, dysphagia, pressure ulcers, repetitive falls) occur when the accumulated effects
of multiple risk factors and impairments in multiple systems render an older person vulnerable to situational
challenges. ‘Geriatric syndrome’ is a poorly defined term that highlights unique features of common health
conditions in older people; they are highly prevalent, multifactorial, and associated with substantial morbidity and
poor outcomes

• symptoms (eg dyspnoea, anxiety)

• social vulnerability or use of resources (eg increased dependency, services, hospitalisations).

Dynamic decline of function, nutritional status, emotional distress and geriatric syndromes are additional prognostic
indicators and are useful for identifying patients for a palliative approach in all three trajectories, and for transition to
end-of-life and terminal care.23,24
Most tools for the early identification of patients with palliative care needs incorporate severity of general indicators of
deteriorating health and some specific clinical indicators.23,24
SPICT was developed to identify patients with advanced chronic conditions who are at risk of deteriorating and dying.
It includes six general factors of poor or deteriorating health, and clinical indicators of multiple life-limiting conditions.
SPICT may assist the GP to identify patients with unmet supportive and palliative care needs for assessment and
care planning earlier in the illness trajectory. 44

Proactive systematic care

There comes a time in treating any patient with progressive chronic illness when death becomes likely in the
foreseeable future, and the focus shifts from the illness to the person, providing the care they want and a good death.
This may be considered at:

• routine assessment (eg 75+ health assessment, comprehensive medical assessment)

• advance care planning

• review of clinical care plan

• onset of advanced chronic disease or incurable cancer

• discharge from hospital treatment (eg acute episode of heart disease, lung disease)

• decline in functional capacity, cognition or geriatric syndromes

• admission into an RACF

• the request of patient and family.

Figure 2 illustrates a framework for GPs providing palliative care for community-based older patients. 45 It supports
GPs to:

• assess palliative care needs

• use available tools

• develop proactive person-centred management plans that reduce the need for decision making in emotionally
charged situations.
12 RACGP aged care clinical guide (Silver Book) Part A. Palliative and end-of-life care

Figure 2. Framework for GPs providing care for community-based patients

Reproduced with permission from Decision Assist. A framework for palliative care in community-based aged care patients. Dickson, ACT:
The Australian & New Zealand Society of Palliative Medicine, 2017.

The framework begins by asking: ‘Would I be surprised if my patient were to die in the next six to 12 months?’.45 This
can be answered by intuition, using clinical and personal knowledge of the patient, and/or clinical tools (eg SPICT) to
identify people who are at risk of deteriorating and dying:

• If the answer is ‘yes’, continue progressive chronic illness management, and initiate or review the patient’s
advance care plan and clinical care plan.

• If the answer is ‘no’, assess the patient’s palliative needs and symptoms, review and use the advance care plan in
discussion with the patient +/– medical decision maker, and initiate a clinical care plan for
– palliative approach: prognosis within 6–12 months
– end-of life-care: prognosis within weeks (<6 months)
– terminal phase, after death and bereavement: prognosis <1 week.

Proactive person-centred approach to palliative care

Identification of a patient’s palliative care needs becomes the starting point for initiating a palliative approach or end-
of-life care. A proactive person-centred approach to palliative care entails the following:

• Identify and assess escalating palliative care needs early

– Identify position along illness trajectory
– Does the patient need care for a palliative approach, end-of-life or terminal phase?
– Consider any physical, psychosocial and spiritual/existential issues
– Consider patient symptoms
– Consider carer burden and needs (eg carer allowance and payment, self-care, respite)
 RACGP aged care clinical guide (Silver Book) Part A. Palliative and end-of-life care 13

– Regularly reassess clinical condition, symptoms, deterioration and palliative care needs

• Discuss and share decision making with the patient, medical decision maker and carer
– Discuss illness trajectory with patient and carer so they understand what is happening, especially at transition
to a palliative approach, end-of-life care or terminal care
– Review advance care plan and patient values, goals and choices, including preferred location of care and
preferred place of death
– Include patients to the extent they can contribute to ensure their needs and dignity remain the primary focus
– Address patient and family concerns (eg give honest answers when asked ‘How long have I got?’, ‘What will
happen?’); family views and issues are important and need to be understood
– Use family and team case conferences when needed; for example, some relatives and RACF staff may need
GP support to accept a resident’s decision for a palliative approach
– Establish clinical goals of care and treatment decisions with patient and medical decision maker

• Create a GP clinical care plan, tailored to address

– location of care (at home or RACF)
– any physical, psychosocial and spiritual/existential issues
– clinical care and control of symptoms
– medication management, including deprescribing (refer to Part A. Depresecribing) and rationalising medicines
as clinical condition changes (refer to Part A. Medication management)
– services needed, and avoidance of unwanted treatments
– aids and equipment (eg assistance with activities of daily living, mobility)
– crisis management, emergency and after-hours care
– patient and carer education and support, respite

• Document and share the care plan, and review regularly and revise as needed for palliative approach, end-of-life
or terminal phase

• Make team care arrangements

– Different arrangements for care at different locations; some patients will transfer between locations for specific
treatments or as needs change towards the end of life
– Be familiar with My Aged Care, Aged Care Assessment Service (ACAS) and funding arrangements for home
supports and RACFs; refer early to allow for funding delays
– Team members may include
- practice nurses in general practice who can help with health assessments, advance care planning, care
plans, clinical care, support for patients and family, liaison with other services
- home-care community services (eg personal care, community nursing, occupational therapy,
physiotherapy, palliative care, pharmacy)
- RACF staff, pharmacist, allied health, pastor, specialist palliative and support services

• Engage other community services (eg after-hours doctors, ambulance service, medical specialists, hospice care,
dementia advisory and hospital outreach services, funeral director, carer respite, informal care networks, service
groups and Compassionate Community organisations)
– GPs can coordinate or participate in case conferences, 46,47 shared care arrangements, and telehealth
consultations
– Ensure documentation (eg the appointed medical decision maker, advance care plan, advance care directive,
care plan) is available for continuity of care between all care providers, including after-hours doctors and
ambulance

• Ensure practice organisation is maintained

– Work collaboratively with practice nurse, GP colleagues, general practice registrars, after-hours doctors, other
specialist medical practitioners, and allied health professionals
14 RACGP aged care clinical guide (Silver Book) Part A. Palliative and end-of-life care

– Establish a palliative care patient register

– Use medical software templates and reminder systems
– Use Medicare Benefits Schedule (MBS) item numbers for GP attendance (at practice, home or RACF;
including after hours, emergency and telehealth consultations), health assessments, care plans, and case
conferences
– Use clinical apps, tools and guidelines
– Store and share relevant documentation with other service providers as needed

Clinical care plans

Table 1 illustrates the PEPSI COLA mnemonic from the National Gold Standards Framework, which covers most
potential problems in palliative care for GP clinical care planning.25 It provides a structure to consider a patient’s
holistic needs, which is helpful for assessments, promoting communication with the patient, and documenting the
clinical care plans as the patient approaches death.14

Table 1. The PEPSI COLA structure for palliative care clinical planning

Domain Issues to consider

Physical • Symptom control
• Medication – regular and as needed
• Compliance/stopping non-essentials
• Complementary therapies
Emotional • Understanding expectations
• Depression and adjustment
• Fears/security
• Relationships
Personal • Spiritual/religious needs
• Inner journey
• Quality of life
• Patient/carer agenda
Social support • Benefits/financial
• Care for carers
• Practical support
Information/communication • Within team
• Between professionals
• To and from patient
• To and from carers
Control • Choice, dignity
• Treatment options/management plan
• Advance directive
• Place of death
Out of hours/emergency • Continuity
• Provision of out-of-hours care to patients/carers
• Carer support
• Medical support
• Drugs and equipment
Late • End-of-life/terminal care
• Stop non-urgent treatment
• Patient and family aware
• Comfort measures/spiritual care
• Rattle, agitation
 RACGP aged care clinical guide (Silver Book) Part A. Palliative and end-of-life care 15

Afterwards • Bereavement follow-up/others informed

• Family support
• Assessment/audit
• Support team

As described in Box 1, there is ideally a shift in focus of clinical care as the patient progresses along the illness
trajectory and approaches death. Regular patient reassessment can lead to early recognition of escalating palliative
care needs and reduce patient distress by enabling a smoother transition to palliative approach, end-of-life and
terminal phase.

Palliative approach
The focus of care in the palliative approach shifts from life-prolonging treatments towards symptom treatment and
quality of remaining life. In the palliative approach, GPs should:

• discuss the trajectories (physical, social, psychological, spiritual/existential) with patients and carers

• provide palliative care ongoing with disease management

– anticipate and manage symptoms, illness exacerbations, and acute events
– introduce interventions to optimise the person’s level of comfort, function and wellbeing
– address personal values and advance care planning for future care
– make early referrals and team care arrangements
– use case conferences to agree on issues and goals, and coordinate care between service providers
– monitor for deterioration and escalating needs

• avoid unwanted non-beneficial interventions or hospitalisation

– non-beneficial interventions that will not be effective in treating a person’s medical condition or improving their
quality of life may include diagnostic tests, medications, artificial hydration and nutrition, intensive care, and
medical or surgical procedures. Non-beneficial treatments are sometimes referred to as ‘futile’ or
‘inappropriate’; however, these are not the preferred terms 48,49

• address carers’ needs

– carers are often the main care providers of palliative care patients while living at home. Identifying and
supporting carers is important. Carers’ needs and burnout are substantial, and often overlooked because they are
not the ill person 50
– the Needs Assessment Tool for Carers of people dying with cancer (NAT-C) and non-cancer (NAT-CC) are
available as self-completed checklists. NAT-C improves outcomes for carers, particularly those with anxiety or
depression. 51

• regularly review symptoms and changes in clinical condition.

End-of-life care
The focus of end-of-life care is on providing increased services and support for the person’s physical, emotional,
social and spiritual/existential issues as they approach death. It entails:

• different arrangements according to preferred place of care and death

• frequent symptom reviews and changes in treatment as the person’s health deteriorates

• preparing for the terminal phase

• support for patient, family and carers

– communicate prognosis
– respect the patient and their family’s wishes, and review patient values, advance care plan, and advance care
directive
16 RACGP aged care clinical guide (Silver Book) Part A. Palliative and end-of-life care

– listening to carers and family experiences and bereavement arrangements will help carers and family
members achieve peaceful closure
– enable carers, friends and family to be present before and at time of death if this is the desire of the patient
– if wanted, help arrange spiritual or religious support in a timely manner

• rationalising medicines
– review medicines and deprescribe medicines that are of no short-term benefit (refer to Part A. Deprescribing).
– consider anticipatory prescribing for common symptoms and acute/crisis events
– consider use of subcutaneous drug administration if patient is unable to swallow
– use tools (eg palliAGEDgp app, palliMEDS app, Opioid Calculator app)

• turning off implantable defibrillators (if patient is known to have one) so as not to discharge upon death. For
advice, contact the manufacturer or cardiologist.

Care at home

Patients need to have their symptoms well managed for them to be able to stay at home for as long as possible, and
to die at home. Anticipate the possibility that the person may be cared for at home for all but the last few days of life,
when transfer may occur because of rapidly escalating care needs not able to be met at home, patient safety risks or
carer exhaustion.
Make arrangements for care at home and empower carers by providing the necessary knowledge and tools,
including:

• how and when to contact service providers, including after-hours care (eg palliative care, community care, GP,
locum doctor, pharmacist, ambulance service, funeral director)

• arranging or checking equipment needed (eg diet, dressings, rails, commodes, personal medical alert alarm and
system)

• training and giving confidence to carers to administer subcutaneous medication for prompt management of pain
and other symptoms

– assist in educating family on care and use/administration of medicines (eg via caring@home)
– ensure backup, supply, and equipment for administration of medicine

• arranging for collection of equipment and removal of medications (including Schedule 8 drugs and sharps) after
death

• ensuring death-at-home documentation is available (eg advance care plan, advance care directive, ‘not for
resuscitation’ orders).

Terminal phase and after-death care

Recognising that death is imminent can sometimes be difficult, particularly if the person is declining gradually. Within
hours to days of death, several of the following symptoms and signs (not explained by a reversible cause) may be
present: 52

• Increased trajectory of deterioration

• Peripheral shutdown and cyanosis, changes in respiratory patterns (eg Cheyne–Stokes breathing), retained
upper airways secretions

• Drowsiness and reduced cognition (ie no response to verbal and/or physical stimuli)

• Uncharacteristic or recent restlessness and agitation

• Reduced or absent urinary content

• Cardiac signs (eg hypotension, tachycardia)

• Decreased mobility (eg bed bound)

• Decreased ability to swallow safely

 RACGP aged care clinical guide (Silver Book) Part A. Palliative and end-of-life care 17

The focus of care in the terminal phase is on enabling a ‘good death’ with dignity, relief from pain and other
symptoms, and respecting the person’s preference of place of death and who is present. Terminal care priorities are
as follows:

• Provide support and communicate diagnosis of dying and likely course to the patient, family and service providers

• If the patient lives in an RACF, commence residential aged care end-of-life (terminal) pathway

• Monitor and address symptoms with nursing care and medications

• Cease non-essential medications, review anticipatory prescribing and ensure appropriate medications are
available

• Discuss what to do after death

– carers and family can have time alone with the person before contacting person to certify death, and the
funeral director
– arrangement of death certificate
– bereavement support
– document bereavement follow-up plan

After death

After the death of a patient, the GP can ensure practical tasks are performed:18

• Oversee completion of legal requirements

– death is to be verified by an authorised person – medical practitioner, nurse or paramedic
– if the body is to be cremated, inform funeral director of hazards to be removed (eg implanted pumps, cardiac
devices, radioactive isotopes, implants)
– some deaths must be reported to the coroner; if in doubt, contact the state or territory coroners’ office to
discuss
– death certificate is to be completed by medical practitioner (requirements vary by state or territory)

• Make sure carers and family are aware they can have time alone with the person before contacting the
practitioner to certify death

• Offer to contact a funeral director or minister of religion (may be done by family member or RACF staff)

• Offer bereavement support

• Inform community nursing team or palliative care team; they can organise support for the family

• Organise collection of equipment, removal of medications, including Schedule 8 drugs and sharps

• Inform relevant health providers and health services

Symptom control
Patients with life-limiting illness frequently develop symptoms because of progression, relapse or exacerbation of
chronic diseases, treatments and/or intercurrent illness. Early identification, assessment and management are
important to relieve symptoms and improve quality of life. Assess each symptom, its impact, cause and effect of
previous treatments, and consider priorities for the patient.18
In a systematic review of general practice end-of-life symptom control, most GPs expressed confidence in identifying
end-of-life care symptoms. However, they reported lack of confidence in providing end-of-life care at the beginning of
their careers, and improvements with time in practice. They perceived emotional support as the most important
aspect of end-of-life care that they provide. GPs felt most comfortable treating pain, and least confident with
dyspnoea and depression. Observed pain management was sometimes not optimal. More formal training, particularly
in the use of opioids, was considered important to improve management of both pain and dyspnoea. 53
Symptom assessment tools can be valuable to identify symptoms, score their severity and monitor the effectiveness
of treatments. A useful tool for GPs is the Symptom Assessment Scale (SAS), which is available in 15 languages for
18 RACGP aged care clinical guide (Silver Book) Part A. Palliative and end-of-life care

completion by patients, their carer or RACF staff. It lists and scores severity on a scale of 0–10 for seven common
symptoms (with ability to add extra symptoms) in palliative care:

• Difficulty sleeping

• Appetite problems

• Nausea

• Bowel problems

• Breathing problems

• Fatigue

• Pain (refer to Part A. Pain)

Physical issues and symptoms to be considered in palliative care for people with dementia include monitoring for
non-verbal pain behaviours, falls (refer to Part A. Falls), vision, oral health, swallowing difficulties, seizures and
withdrawal effects of deprescribing medication.
Refer to clinical guidelines (eg eTG Palliative Care,18 CareSearch) 54 for detailed assessment and management of
common physical symptoms and problems at the end of life, including pain, fatigue, gastrointestinal, respiratory,
neurological and neuromuscular, psychological, dermatological, haematological, genitourinary, and emergencies.18
Many of the troubling symptoms of the terminal phase can be remembered under the mnemonic PANERO:52

• Pain

• Agitation

• Nausea (and vomiting)

• Emergencies (eg acute severe):18

– vomiting
– dyspnoea
– airway obstruction
– superior vena cava obstruction
– agitation and altered mental state
– haemorrhage
– seizures
– spinal cord compression

• Respiratory symptoms (eg noisy breathing)

• Other symptoms (related to the specifics of the terminal illness)

Principles of symptom management include the following:18

• Closely monitor patients’ symptoms and individualise treatment as needed

• Minimise the burden of treatment and number of medications

• Communicate and document plan to patient, carer and treating health providers

• Frequently review symptom and management

 RACGP aged care clinical guide (Silver Book) Part A. Palliative and end-of-life care 19

Medication management in palliative care

Principles
Issues to consider for safe use of medicines in palliative care include: 55

• monitoring for effectiveness and adverse effects

• minimising burden on patients

• polypharmacy (refer to Part A. Polypharmacy)

• deprescribing (refer to Part A. Deprescribing)

• safety of opioid use and disposal

• complexities of opioid prescribing.

Key principles for medication management at the end of life are as follows:18

• Assess and closely monitor patients and individualise treatment as needed

• Continue current medicines if needed for symptom control

• Stop unnecessary, burdensome or harmful medicines

• Consider anticipatory prescribing

• Prescribe regular medicines for ongoing symptoms and as required for intermittent or breakthrough symptoms

• Keep the patient comfortable by ensuring adequate doses

• Administer medicines subcutaneously or sublingually

• Consider practical aspects of subcutaneous administration (eg injection volumes, medicine compatibility, skill of
carers)

• Monitor effects and adjust dose

• Seek palliative care advice if a patient is distressed or does not settle despite adequate doses
Alleviating suffering and ensuring a patient can maintain their dignity and some sense of control as their life comes to
an end is the essence of good palliative care.18 However, in the terminal phase, GPs may be concerned that they
could prescribe or administer a medicine that will unintentionally lead to a patient’s death.25
In Australian law, the ‘doctrine of double effect’ recognises that giving medicines (usually by a health professional) to
a patient to relieve pain is lawful, even if it could hasten death. The two critical elements of ‘double effect’ are
intention and that the patient’s death is imminent. If the primary intention is to relieve pain and symptoms, not cause
death, the person who gave the medicine will not be criminally responsible for a death which follows, even if it is
foreseen. For further information, refer to ‘Palliative Medicine’ on the End of Life Law in Australia website.

Deprescribing
Deprescribing is the withdrawal of medicines that are no longer beneficial. It is a key component of palliative care. For
current medicines prescribed for long-term effects, assess risks, short-term benefits and potential withdrawal effects,
including:

• medicines for cardiovascular disease (ie hypertension, angina, dyslipidaemia), diabetes, cancer, epilepsy,
neurological diseases, psychiatric illness

• anticoagulants and antiplatelet medications, thyroid replacement, antivirals (human immunodeficiency virus [HIV],
hepatitis), corticosteroids.
Changes should occur gradually unless the patient is close to death, has minimal oral intake and is unable to take
their usual medicines.
20 RACGP aged care clinical guide (Silver Book) Part A. Palliative and end-of-life care

Prescribing
Medications used in palliative care are available as no script (‘over the counter’), private script, Pharmaceutical
Benefits Scheme (PBS) script, PBS Authority script and PBS Authority (Palliative Care). Medicines listed in the PBS
Palliative Care Schedule are ‘authority required’; larger quantities can be prescribed, reducing burden in terms of
costs and need for repeat prescriptions.
‘Off-label’ medications are often prescribed as private scripts for palliative care patients for a different indication or
route than the one for which they are approved by the Therapeutic Goods Administration (TGA). Palliative care
services can provide advice to GPs based on considerable clinical experience with common off-label uses of
medications in palliative care, such as:

• antipsychotics or antihistamines for nausea

• antidepressants or anticonvulsants for neuropathic pain

• administration of intravenous (IV) preparations by the subcutaneous route.

Anticipatory prescribing is prescribing medicines in advance for anticipated symptoms or problems, or to avoid crisis
or urgent hospital transfer. GPs can promote effective symptom management in the community by anticipatory
prescribing for common end-of-life symptoms and involving carers in symptom management.

Table 2 is a consensus-based list of eight palliative care medicines suitable for managing terminal symptoms in the
community. It has been endorsed by the Australian and New Zealand Society of Palliative Medicine (ANZSPM).

Table 2. Consensus-based list of eight palliative care medicines suitable for managing terminal symptoms in
the community

Medication Ampoule strength Stock

Clonazepam drops (PBS-listed for seizures only) 2.5 mg/mL 1 bottle (10 mL)
Fentanyl citrate injection (not listed on PBS) 100 mcg / 2 mL 10 ampoules
Haloperidol injection 5 mg/mL 10 ampoules
Hydromorphone injection 2 mg/mL 5 ampoules
Hyoscine butylbromide injection 20 mg/mL 5 ampoules
Metoclopramide injection 10 mg/ 2 mL 10 ampoules
Midazolam injection (not listed on PBS) 5 mg/mL 10 ampoules
Morphine sulphate injection 10 mg/mL 5 ampoules

Details on prescribing these medicines with doses for patients’ symptoms are available in the Resources section.

Bereavement support

Support for carers and family

Most bereaved people do not require counselling or specialist support. Simple reassurance, acknowledgment of their
loss and access to information may be all that is required. Reactions commonly seen as part of normal grief include:50

• physical – hollowness in stomach, tightness in the throat or chest, oversensitivity to noise, sense of
depersonalisation, breathlessness, dry mouth, muscle weakness, lack of energy

• behavioural – crying, sighing, sleep disturbance, restlessness and overactivity, appetite

disturbances, absentmindedness, social withdrawal, dreams of the deceased, avoiding reminders, searching and
calling out, visiting places associated with the deceased, carrying reminders

• mental – disbelief, confusion, preoccupation

• emotional – anxiety, fear, sadness, anger, guilt, inadequacy, hurt, relief, loneliness.
 RACGP aged care clinical guide (Silver Book) Part A. Palliative and end-of-life care 21

Bereavement has a significant effect on the health of surviving family members. Grief can cause poorer health
outcomes, depression, and alcohol and drug dependency in some people. Mortality of the surviving spouse doubles
in the 12 months after the death. Issues to consider in bereaved people include:50

• sleep problems and fatigue, worsening memory

• clinically significant depression – this may occur in 10–20% of bereaved people (refer to Part A. Mental health)

• changed social circumstances – this can affect the bereaved person’s physical activity levels, nutritional status,
and self-management of chronic health problems

• social isolation and changes in other important relationships.

Strategies to actively follow up recently bereaved people in general practice may include:50

• offering an appointment to talk about what happened with a GP; this may be appreciated, particularly if the GP
cared for both deceased and bereaved

• flagging bereaved patients for the practice nurse to contact by condolence letter or a phone call with an offer of a
check-up

• offering to review the bereaved person’s overall health status and medical conditions when they attend the clinic

• identifying bereaved persons who need specialist support.

Support for healthcare professionals

GP self-care and support of colleagues is important to prevent stress and burnout from accumulated losses and grief
associated with providing palliative care, especially in a solo practice or rural setting. Measures for self-care include:18

• education, training, and skills development for palliative care, including communication skills

• self-awareness and realistic expectations

• workload and work–life balance

• expressing grief and sharing experiences of loss (eg of long-term or close patients)

• peer and professional support with colleagues, mentors, professional supervision

• debriefing with colleagues, multidisciplinary case conferences.

Resources
Professional development
GPs are encouraged to develop palliative care skills and experience early in their career. This can be built on and
enhanced by:

• using tools and resources (listed below) to supplement palliative care practice

• shared care with local team-based support services, including community home-based and RACF services;
informal care networks, service groups and Compassionate Community organisations; specialist palliative care
services and hospice care

• peer support and training, including

– GP palliative care interest groups (eg primary health networks [PHNs], The Royal Australian College of
General Practitioners [RACGP])
– membership of the ANZSPM, which provides professional development to support and educate Australian and
New Zealand medical practitioners with an interest in palliative medicine
– the Program of Experience in the Palliative Approach (PEPA), which is a clinical attachment and e-learning
program
– web-based and group training programs in advance care planning, communications skills, advanced chronic
disease, palliative care
22 RACGP aged care clinical guide (Silver Book) Part A. Palliative and end-of-life care

– Advance Project, which is a toolkit and training package to help GPs and practice nurses initiate advance care
planning, assess likely end-of-life care needs, and provide team-based palliative care in everyday clinical
practice
– CareSearch
– end-of-life law for clinicians.

Clinical applications
• SPICT app

• palliAGEDgp – this is available as an app or online for GPs to support care of older palliative patients living at
home or in RACFs. An offline capacity makes it practical for use in remote and rural settings. It provides free,
accessible, evidence-based information to help clinical decision making for each phase of palliative care:

– Advance care planning

– Case conferencing
– Terminal care management
– Prescribing guidance
• palliMEDs – this app is useful for anticipatory prescribing at end of life. It was developed by NPS MedicineWise
for caring@home as a guide to prescribing eight palliative care medicines, was endorsed by the ANZSPM for
management of terminal symptoms, and covers off-label prescribing and medico-legal issues

• Opioid Calculator – this tool simplifies the calculation of equianalgesia expressed as total oral morphine
equivalent daily dose (oMEDD), and was developed by the Faculty of Pain Medicine, Australian and New Zealand
College of Anaesthetists.

Clinical tools
• SPICT

• NAT-C or NAT-CC Caregiver needs assessment – these are needs-assessment tools for carers of people dying
with cancer and non-cancer. They are available as self-completed checklists for carers, which allows them to
identity their own major concerns. These are available online and can be discussed in a GP consultation

• Palliative Care Outcomes Collaboration (PCOC) – PCOC uses five clinical assessment tools to help identify and
manage common symptoms, evaluate effectiveness of treatments, and help patients, carers and families to
communicate their experiences and preferences. Specific useful tools for GPs are:
– SAS (clinical assessment tools to help identify and manage common symptoms, available in 15 languages)
– Australia-modified Karnofsky Performance Status (AKPS) (score of physical abilities across activity, work and
self-care).

Guidelines and resources

• Localised palliative care and advance care planning pathways are divided by area in Australia and available from
local PHNs. The pathways are designed and written for use during the consultation and provide clear concise
guidance for patient assessment, management, and referral to local health services. Included are pathways that
contain information specific to Aboriginal and Torres Strait Islander peoples and culturally and linguistically
diverse communities.

• Therapeutic Guidelines: Palliative care provides practical detailed clinical guidelines, including palliative care and
symptom management, decision making and ethical challenges, communication, support for carers and families,
medications and prescribing, terminal care, and bereavement support.

• CareSearch – the GP section provides easy-to-navigate guidance at all points along the patient’s pathway of
care, including patient assessment, planning care, symptom assessment and management, clinical decisions, the
dying patient, bereavement, use of the PBS and MBS, and professional practice (ongoing education and self-
care). It also provides advice on prescribing and symptom-management advice, psychosocial complexity and
 RACGP aged care clinical guide (Silver Book) Part A. Palliative and end-of-life care 23

refractory symptoms, clinical decision making for the deteriorating patient, emergencies, and planning for a home
death. Refer to the following links for specific information.
– Communication
– Clinical care issues
– Residential Aged Care Palliative Approach Toolkit
– Caregiver needs assessment
– Bereavement

• Advance Care Planning Australia – this website provides extensive resources on advance care planning.

• Palliative Care Australia provides resources for palliative care and advance care planning tailored for use for
people from culturally and linguistically diverse backgrounds. Important patient resources for GPs include:
– multilingual brochures about palliative care
– ACPTalk.

• Caring@home provides resources to support GPs in promoting effective symptom management by anticipatory
prescribing for common end-of-life symptoms, and involving carers in symptom management, including preparing
and giving subcutaneous medicines for breakthrough symptoms. The resource includes the palliMEDS app.

• End of Life Law in Australia informs clinicians of the law, their rights and duties; helps navigate challenging legal
issues that can arise with end-of-life decision making in each Australian state and territory; and provides GP
training modules. Legal issues covered include palliative medicine, euthanasia and assisted dying, capacity and
consent to medical treatment, advance care directives, stopping treatment, and organ donation.

References

1. Australian Institute of Health and Welfare. Changes in life expectancy and disability in Australia 1998 to 2009. Canberra: AIHW, 2012.

2. Broad JB, Gott M, Kim H, Boyd M, Chen H, Connolly MJ. Where do people die? An international comparison of the percentage of
deaths occurring in hospital and residential aged care settings in 45 populations, using published and available statistics. Int J Public
Health 2013;58(2):257–67.

3. Australian Institute of Health and Welfare. Australia's health 2014. Canberra: AIHW, 2014.

4. Swerrisen H, Duckett S. Dying well. Melbourne: Grattan Institute, 2014. Available at https://grattan.edu.au/wp-
content/uploads/2014/09/815-dying-well.pdf [Accessed 14 August 2019].

5. Rosenwax LK, McNamara BA, Murray K, McCabe RJ, Aoun SM, Currow DC. Hospital and emergency department use in the last
year of life: A baseline for future modifications to end-of-life care. Med J Aust 2011;194(11):570–73. Available at
www.mja.com.au/journal/2011/194/11/hospital-and-emergency-department-use-last-year-life-baseline-future [Accessed 14 August
2019].

6. Walling AM, Asch SM, Lorenz KA, et al. The quality of care provided to hospitalized patients at the end of life. Arch Intern Med
2010;170(12):1057–63.

7. Marck CH, Weil J, Lane H, et al. Care of the dying cancer patient in the emergency department: Findings from a National survey of
Australian emergency department clinicians. Intern Med J 2014;44(4):362–68.

8. Pollock K. Is home always the best and preferred place of death? BMJ 2015;351:h4855.

9. Brazil K, Howell D, Bedard M, Krueger P, Heidebrecht C. Preferences for place of care and place of death among informal caregivers
of the terminally ill. Palliat Med;19(6):492–99.

10. Smith R. A good death. An important aim for health services and for us all. BMJ 2000;320(7228):129–30.

11. Singer PA, Martin DK, Kelner M. Quality end-of-life care: Patients' perspectives. JAMA 1999;281(2):163–68.

12. Department of Health. National Palliative Care Strategy 2018. Canberra: DoH, 2018.

13. World Health Organization. WHO definition of palliative care. Geneva: WHO, 2018. Available at
www.who.int/cancer/palliative/definition/en [Accessed 14 August 2019].

14. Palliative Care Australia. What is palliative care? Griffith, ACT: PCA, 2018. Available at https://palliativecare.org.au/what-is-palliative-
care [Accessed 14 August 2019].

15. palliAGED. A palliative approach. Adelaide: Flinders University, 2018. Available at www.palliaged.com.au/tabid/4351/Default.aspx
[Accessed 14 August 2019].
24 RACGP aged care clinical guide (Silver Book) Part A. Palliative and end-of-life care

16. Queensland University of Technology. End-of-life law for clinicians. Brisbane: QUT, 2018. Available at https://end-of-life.qut.edu.au
[Accessed 14 August 2019].

18. Palliative Care Expert Group. Palliative care, version 4. Melbourne: Therapeutic Guidelines Ltd, 2018.

19. Rhee JJ, Zwar NA, Kemp LA. Why are advance care planning decisions not implemented? Insights from interviews with Australian
general practitioners. J Palliat Med 2013;16(10):1197–204.

20. Lund SR, May C. Barriers to advance care planning at the end of life: An explanatory systematic review of implementation studies.
PLoS One 2015;10(2).

21. De Vleminck A, Pardon K, Beernaert K, et al. Barriers to advance care planning in cancer, heart failure and dementia patients: A focus
group study on general practitioners' views and experiences. PLoS One 2014;9(1):e84905.

22. Caplan GA, Meller AE. Advance care planning in aged care facilities. Australas J Ageing 2013;32(4):202–03.

23. Murray SA, Kendall M, Boyd K, Sheikh A. Illness trajectories and palliative care. BMJ 2005;330:1007.

24. Amblàs-Novellas J, Murray SA, Espaulella J, et al. Identifying patients with advanced chronic conditions for a progressive palliative
care approach: A cross-sectional study of prognostic indicators related to end-of-life trajectories. BMJ Open 2016;6:e012340.

25. White BP, Willmott L, Neller P. End of life law in Australia. Brisbane: Queensland University of Technology, 2019. Available at https://end-
of-life.qut.edu.au [Accessed 14 August 2019].

26. Advance Care Planning Australia. A routine part of health and personal care. Melbourne: Austin Health, 2018. Available at
www.advancecareplanning.org.au [Accessed 14 August 2019].

27. Bird S. Advance care planning. Aust Fam Physician 2014;43(8):526–28.

28. Brinkman-Stoppelenburg A, Hancock AD, Reade MC, Silvester W. The effects of advance care planning on end-of-life care:
A systematic review. Palliat Med 2014;28(8):1000–25.

29. Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients:
Randomised controlled trial. BMJ 2010;340.

30. Carter RZ, Detering KM, Silvester W, Sutton E. Advance care planning in Australia: What does the law say? Aust Health Rev
2016;40(4):405–14.

31. Abel J, Pring A, Rich A, et al. The impact of advance care planning on place of death, a hospice retrospective cohort study. BMJ
Support Palliat Care 2013;3:168–73.

32. Scott I. Physicians need to take the lead in advance care planning. Intern Med J 2014;44(10):937–39.

33. Scott IA, Mitchell GK, Reymond EJ, Daly MP. Difficult but necessary conversations – The case for advance care planning. Med J
Aust 2013;199(10):662–66.

34. Street M, Ottmann G, Johnstone MJ, Considine J, Livingston PM. Advance care planning for older people in Australia presenting to the
emergency department from the community or residential aged care facilities. Health Soc Care Community 2015;23(5):513–22.

35. Johnson CE, Singer R, Masso M, Sellars M, Silvester W. Palliative care health professionals' experiences of caring for patients with
advance care directives. Aust Health Rev 2015:39(2):154–59.

36. The Royal Australian College of General Practitioners. RACGP Position statement: Advance care planning should be incorporated into
routine general practice. East Melbourne, Vic: RACGP, 2012. Available at
www.racgp.org.au/download/documents/Policies/Clinical/advancedcareplanning_positionstatement.pdf [Accessed 14 August 2019].

37. Advance Care Planning Australia. A routine part of health and personal care. Melbourne: Austin Health, 2018. Available at
www.advancecareplanning.org.au [Accessed 25 February 2019].

38. Murray SA, Kendall M, Mitchell G, Moine S, Amblàs-Novellas J, Boyd K. Palliative care from diagnosis to death. BMJ 2017;356:j878.

39. Palliative Care Australia. National palliative care standards. 5th edn. Canberra: PCA, 2018. Available at http://palliativecare.org.au/
wp-content/uploads/dlm_uploads/2018/02/PalliativeCare-National-Standards-2018_web-3.pdf [Accessed 14 August 2019].

40. CareSearch. Aboriginal and Torres Strait Islander care. Adelaide: Flinders University, 2018. Available at
https://www.caresearch.com.au/tabid/6823/Default.aspx [Accessed 14 August 2019].

41. Murray SA, Amblàs-Novellas J. Palliative care from diagnosis to death. Edinburgh: Primary Palliative Care Research Group, Centre for
Population Health Sciences, University of Edinburgh, 2017.

42. Downar J, Goldman R, Pinto R, Englesakis M, Adhikari NK. The ‘surprise question’ for predicting death in seriously ill patients:
A systematic review and meta-analysis. CMAJ 2017;189(13):E484–93.

43. Mitchell GK, Senior HE, Rhee JJ, et al. Using intuition or a formal palliative care needs assessment screening process in general
practice to predict death within 12 months: A randomised controlled trial. Palliat Med 2018;32(2):384.

44. Highet G, Crawford D, Murray SA, Boyd K. Development and evaluation of the Supportive and Palliative Care Indicators Tool (SPICT):
A mixed-methods study. BMJ Support Palliat Care 2014;4:285–90.

45. Reymond L, Cooper K, Parker D, Chapman M. End-of-life care: Proactive clinical management of older Australians in the community.
Aust Fam Physician 2016:45(1–2):76–78. Available at www.racgp.org.au/afp/2016/januaryfebruary/end-of-life-care-proactive-clinical-
management-of-older-australians-in-the-community [Accessed 14 August 2019].

46. palliAGED. Case conferencing – Synthesis. Adelaide: Flinders University, 2017. Available at
www.palliaged.com.au/tabid/4464/Default.aspx [Accessed 14 August 2019].
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47. Department of Health. MBS Online – Note AN.0.49. Available at

www9.health.gov.au/mbs/fullDisplay.cfm?type=note&q=AN.0.49&qt=noteID&criteria=Case%20Conference [Accessed 14 August
2019].

48. palliAGED. Terminal care – Synthesis. Adelaide: Flinders University, 2018. Available at
www.palliaged.com.au/tabid/4466/Default.aspx [Accessed 14 August 2019].

49. Australian Commission on Safety and Quality in Health Care. National Consensus Statement: Essential elements for safe and high-
quality end-of-life care. Sydney: ACSQHC, 2015. Available at www.safetyandquality.gov.au/publications/national-consensus-
statement-essential-elements-for-safe-high-quality-end-of-life-care [Accessed 14 August 2019].

50. CareSearch. Bereavement. Adelaide: Flinders University, 2019. Available at

www.caresearch.com.au/tabid/6263/Default.aspx [Accessed 14 August 2019].

51. Mitchell GK, Girgis A, Jiwa M, Sibbritt D, Burridge LH, Senior HE. Providing general practice needs-based care for carers of people
with advanced cancer: A randomised controlled trial. Br J Gen Pract 2013;63(615):e683–90.

52. Ellershaw J, Wilkinson S, editors. Care of the dying – A pathway to excellence. New York: Oxford University Press, 2003.

53. Mitchell G, Senior H, Johnson C, et al. Systematic review of general practice end-of-life symptom control. BMJ Support Palliat Care
2018;pii:bmjspcare-2017-001374.

54. CareSearch. Symptoms. Adelaide: Flinders University, 2019. Available at

www.caresearch.com.au/tabid/6260/Default.aspx [Accessed 14 August 2019].

55. CareSearch. Prescribing. Adelaide: Flinders University, 2019. Available at

www.caresearch.com.au/tabid/6314/Default.aspx [Accessed 14 August 2019].
 RACGP aged care clinical
guide (Silver Book)
5th edition
Part A. Deprescribing

General principles
Deprescribing is a positive, patient-centred intervention, conducted under medical supervision, that reassesses
the role of all medicines with a view to stopping those that:1

• have no clear benefit

• may cause harm

• are being used for an indication that is no longer an issue

• no longer fit with the current goals of care.

Practice points
Practice points References Grade
Deprescribing should be undertaken with the assistance of a – Consensus-based
multidisciplinary care team, and appropriately communicated to all recommendation
members of the care team
Establish a written tapering plan, especially for classes of 10, 11 Consensus-based
medication that require slow tapering (eg opioids, recommendation
benzodiazepines), to avoid a return of disease symptoms or
withdrawal symptoms
Explain to the patient that deprescribing is a positive intervention 1, 15, 18 Consensus-based
aimed at improving quality of life, and ensuring they do not receive recommendation
unnecessary medicines with unlikely benefit or potential for harm
Review and reconcile medicines with other medicine lists, including 1, 19–21 Consensus-based
those from a Home Medicines Review (HMR) or Residential recommendation
Medication Management Review (RMMR), patient medicine list or
discharge summary, with your current medicine list in your record
2 RACGP aged care clinical guide (Silver Book) Part A. Deprescribing

Assess medicine-related benefits and risk of harm, and discuss 1, 19–21 Consensus-based
options with patient, resident, family and advocate recommendation
Discuss, prioritise and plan any changes with patient and family 1, 19–21 Consensus-based
and advocate to decide and agree on specific medicines to change, recommendation
generally one at a time, slowly over weeks or months, in a stepwise
approach

Introduction
Deprescribing is the process of withdrawal of an inappropriate medication, supervised by a healthcare professional,
with the goal of managing polypharmacy and improving outcomes (refer to Part A. Polypharmacy). 1 Deprescribing
should be considered at all times as part of good prescribing continuum, not just at the end-of-life stage. It should be
undertaken with the assistance of a multidisciplinary care team that may involve general practitioners (GPs),
pharmacists, residential aged care facility (RACF) staff, registered nurses, other specialist medical practitioners, and
allied health professionals.
Research and evidence in deprescribing is lacking, and needs to be an area of research priority in general practice
and RACFs.

Clinical context
Potential benefits
Potential benefits of deprescribing include:1,2,3,4, 5,6,7

• reducing potential for drug interactions and adverse effects

• improving function and quality of life (eg may improve cognition and behaviour, and may reduce rate of falls)

• simplifying drug regimens (although this can occur without deprescribing)

• reducing costs for patient and nursing staff (if in care)

• reducing medication errors.

Potential harms
Signs and symptoms of the original condition may reappear when a drug is withdrawn. If this occurs, consider a
reduced dose or frequency (eg from regular to ‘as needed’ pro re nata [PRN] dosing), rather than complete cessation.

Potential changes in pharmacokinetic and pharmacodynamic drug interactions should be considered when
deprescribing; for example, international normalised ratio (INR) changes in a patient taking warfarin when an
interacting drug is ceased.1
The risk of clinically significant adverse withdrawal reactions is rare when deprescribing is undertaken slowly and
appropriately under medical supervision. However, while withdrawal reactions may occur, it is important not to
interpret these as recurrence of symptoms of the original disease. Withdrawal syndromes may include:

• withdrawal effects (eg confusion, seizures after abrupt withdrawal of benzodiazepines)

• rebound effects (eg rebound tachycardia after withdrawal of beta-blocker, rebound acid secretion with abrupt
withdrawal of a proton pump inhibitor).
 RACGP aged care clinical guide (Silver Book) Part A. Deprescribing 3

In practice
A written tapering plan is desirable, especially for classes of medication that require slow tapering (eg opioids,
benzodiazepines), to avoid a return of disease symptoms or withdrawal symptoms. A written tapering plan has the
potential to optimise the patient’s quality of life by reducing medications that are no longer appropriate in their clinical
context.3, 8
Many studies have found the benefits of slow, appropriate reduction of inappropriate medicines in older people,
particularly those living in RACFs. 9, 10 Many guides for slow structured withdrawal of targeted medicines have been
published, including:

• Primary Health Tasmania’s Deprescribing resources: One of the most accessible and practical guides.3

• Canadian Deprescribing Group’s Medstopper: Useful deprescribing tool for health professionals. The Canadian
Deprescribing Group also have deprescribing guidelines and an interest group. 11

• The Evidence-based clinical practice guideline for deprescribing cholinesterase inhibitors and memantine has
been developed by the University of Sydney, in conjunction with the Bruyère Research Institute. 12 The guideline
contains seven recommendations that reflect the current evidence about when and how to trial withdrawal of
cholinesterase inhibitors and memantine. The recommendations were approved by the National Health and
Medical Research Council (NHMRC) in October 2017, and are directed at healthcare professionals. An algorithm
was also developed to assist healthcare professionals in deprescribing.

Table 1 includes some medicines that require care when ceasing.

Table 1. Examples of ceasing medications in older people1,3,13, 14,15

Class Comments
Analgesics Withdrawal syndrome would occur with abrupt cessation of opioids

Antidepressants Slow withdrawal recommended with selective serotonin reuptake inhibitors

(SSRIs)
Antipsychotics Cessation should be gradual, particularly after long-term use

Benzodiazepines Very slow weaning program recommended at 10–15% per week. Sudden
cessation may result in confusion, hallucinations and seizures. 16 Insomnia may
occur with sedative withdrawal
Beta-blockers Abrupt cessation may exacerbate angina, or precipitate rebound hypertension,
myocardial infarction or ventricular arrhythmias
Clonidine, moxonidine Slow weaning to avoid rebound hypertension

Corticosteroids Slow weaning is only required if patients have had long-term therapy

Levodopa Sudden withdrawal may cause neuroleptic syndrome

Proton pump inhibitors Slow weaning to avoid hypersecretion of acid and aggravation of symptoms

Potential barriers to deprescribing

While many patients may be willing to try ceasing medicines, some barriers may exist from a patient perspective,
including:1,3,15,16

• anxiety and fear of consequences of stopping a medicine that has been prescribed for a long period

• reluctance to stop a drug when a patient believes it may prolong life or improve function

• previous negative experiences with drug withdrawal

• the perception that deprescribing suggests that the patient is ‘not worth treating’.

Medical practitioners may also find deprescribing challenging for several reasons, including:1,3,17

• adherence to disease-specific guidelines, which usually do not consider multimorbidities (refer to Part A.
Multimorbidity)
4 RACGP aged care clinical guide (Silver Book) Part A. Deprescribing

• concern about ceasing medicines that another prescriber started

• time constraints

• fear of drug withdrawal syndromes or disease relapse

• difficulty in conducting life expectancy/quality-of-life discussions.

Shared decision making

All prescribers, patients and their family, pharmacists, nurses and allied health professionals are crucial components
of deprescribing. It is important to explain to the patient that deprescribing is a positive intervention aimed at
improving quality of life, and ensuring they do not receive unnecessary medicines with unlikely benefit or potential for
harm. Individual potential risks, benefits and the withdrawal plan should be clearly explained, and patient or family
concerns about deprescribing should be addressed.1,15,18
Patient involvement throughout the process is important to determine if care goals are being met and, if there are any
adverse effects, medical practitioners should reinforce that deprescribing is part of an active treatment plan.

Developing a deprescribing plan

Deprescribing involves:1

• assessing the patient to establish goals of care

• obtaining a comprehensive medication history

• identifying medicine/s that may be appropriate to cease

• prioritising medicine/s that should be ceased first

• developing a cessation plan

• monitoring and documenting outcomes after each medicine has been stopped.

Step 1. Review all medicines

It is important to review all of the patient’s medicines:1,19,20,21

• Review and reconcile medicines with other medicine lists, including those from a Home Medicines Review (HMR)
or Residential Medication Management Review (RMMR), patient medicine list or discharge summary, with your
current medicine list in your record.

• Check with My Health Record.

• Discuss any differences found with the patient, carer, RACF.

• Update the current medicine list.

Step 2. Assess and discuss

Assess medicine-related benefits and risk of harm, and discuss options with patient, resident, family and
advocate:1,19,20,21

• Consider
– number of medicines used
– high-risk medicines
– past or current toxicity
– patient/resident individual circumstances and preferences.

• Ask patient, resident, family and advocate if they are aware of, and understand, their options.

• Explain probable outcomes of continuing or discontinuing medicines, considering

– patient’s age
 RACGP aged care clinical guide (Silver Book) Part A. Deprescribing 5

– cognitive ability
– dexterity problems

– comorbidities
– other prescribers
– past or current adherence.

Step 3. Assess and consider

Assess and consider the ongoing need for each medicine via the following steps:1,19,20,21

• Step 3A. Medicine adds no benefit, due to

– toxicity
– no indication
– diagnosis no longer being appropriate

– contraindication
– cascade prescribing.

• Step 3B. Harm outweighs benefits

– Is anticholinergic load high?

• Step 3C. Symptoms or disease medicines

– Do guidelines suggest withdrawal after a period of stable disease?

• Step 3D. Preventive medicines

– Is the potential benefit of the medicine unlikely to be realised because of limited life expectancy?

• Step 3E. Continue medicine

– Check dose and monitor.

Step 4. Prioritise medicines to be changed

Prioritise medicines that need to be changed by:1,19,20,21

• discussing, prioritising and planning any changes with patient, family and advocate

• asking them what they want

• deciding and agreeing on specific medicines to change, generally one at a time, slowly over weeks or months,
in a stepwise approach.

Step 5. Implement and monitor

Implement the plan and monitor the patient as follows:1,19,20,21

• Initiate the changes in collaboration with patient, family and advocate.

• Highlight any withdrawal syndromes and taper doses where appropriate (refer to Table 1).

• Monitor and check any changes associated with stopping the drug.

• Develop a medication management plan with the patient, family and advocate (refer to Part A. Medication
management).

• Communicate the plan to the nursing staff, carers, accredited pharmacist, community pharmacy and your patient.
6 RACGP aged care clinical guide (Silver Book) Part A. Deprescribing

References
1. Rossi S. AMH Aged care companion. Adelaide: Australian Medicines Handbook Pty Ltd, 2018. Available at https://agedcare.amh.net.au
[Accessed 8 August 2019].

2. Reeve E, Gnjidic D, Long J, Hilmer S. A systematic review of the emerging definition of ‘deprescribing’ with network analysis:
Implications for future research and clinical practice. Br J Clin Pharmacol 2015;80(6):1254–68.

3. Primary Health Tasmania. Deprescribing resources. Hobart: PHT, 2019. Available at

www.primaryhealthtas.com.au/resources/deprescribing-resources [Accessed 8 August 2019].

4. Potter K, Flicker L, Page A, Etherton-Beer C. Deprescribing in frail older people: A randomised controlled trial. PLoS One
2016;11(3):e0149984.

5. Page AT, Clifford RM, Potter K, Schwartz D, Etherton-Beer CD. The feasibility and effect of deprescribing in older adults on mortality
and health: A systematic review and meta-analysis. Br J Clin Pharmacol 2016;82(3):583–623.

6. Page A, Clifford R, Potter K, Etherton‐Beer C. A concept analysis of deprescribing medications in older people. J Pharm Pract Res
2018;48(2):132–48.

7. Potter K, Page A, Clifford K, Etherton-Beer C. Deprescribing: A guide for medication reviews. J Pharm Pract Res 2016;46(4):358–67.

8. National Health Service Scotland. Polypharmacy Guidance – Medicines Review. NHS Scotland, 2019. Available at
www.polypharmacy.scot.nhs.uk/polypharmacy-guidance-medicines-review/for-healthcare-professionals/hot-topics/medication-in-the-
frailest-adults [Accessed 8 August 2019].

9. Kua CH, Yeo CYY, Char CWT, et al. Nursing home team-care deprescribing study: A stepped-wedge randomised controlled trial
protocol. BMJ Open 2017;7:e015293.

10. Wouters H, Quik EH, Boersma F, et al. Discontinuing inappropriate medication in nursing home residents (DIM-NHR Study): Protocol of
a cluster randomised controlled trial. BMJ Open 2014;4:e006082.

11. Deprescribing. Canadian Deprescribing Group. Ontario: Bruyère Research Institute, 2018. Available at https://deprescribing.org
[Accessed 8 August 2019].

12. Reeve E, Farrell B, Thompson W, et al. Deprescribing cholinesterase inhibitors and mematine in dementia: Guideline summary. Med J
Aust 2019;210(4)174–79.

13. Anderson L. Top 6 tips for stopping your meds. Washington DC: Drugs, 2014. Available at www.drugs.com/article/safety-tips-stopping-
meds.html [Accessed 8 August 2019].

14. Best Practice Advocacy Centre New Zealand. A practical guide to stopping medicines in older people. Dunedin: BPACNZ, 2010.
Available at www.bpac.org.nz/BPJ/2010/April/stopguide.aspx [Accessed 8 August 2019].

15. NPS MedicineWise. Older, wiser, safer: Promoting safe use of medicines for older Australians. Canberra: NPS MedicineWise, 2013.
Available at www.nps.org.au/publications/health-professional/nps-news/2013/older-wiser-safer [Accessed 29 March 2019].

16. Anderson K, Stowasser D, Freeman C, Scott I. Prescriber barriers and enablers to minimising potentially inappropriate medications
in adults: A systematic review and thematic synthesis. BMJ Open 2014;4(12):e006544.

17. Reeve E, To J, Hendrix I, Shakib S, Roberts MS, Wiese MD. Patient barriers to and enablers of deprescribing: A systematic review.
Drugs Aging 2013;30(10):793–807.

18. Jansen J, Naganathan V, Carter SM, et al. Too much medicine in older people? Deprescribing through shared decision-making.
BMJ 2016;353:i2893.

19. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: The process of deprescribing. JAMA Intern Med
2015;175(5):827–34.

20. Le Couteur D, Banks E, Gnijidic D, McLachlan A. Deprescribing. Aust Prescr 2011;34(6):182–85.

21. Department of Veterans’ Affairs. Veterans’ medicines advice and therapeutics education services: A guide to deprescribing in
polypharmacy. Canberra: DVA, 2019.
 RACGP aged care clinical
guide (Silver Book)
5th edition
Part A. Medication management

General principles
• As the population ages, more people are living with multiple chronic diseases with an associated increase in
polypharmacy (multiple medicines use).
• Medication use in older people is a complex balance between managing disease and avoiding medication-
related problems.
• Supervised withdrawal of unnecessary medicines (deprescribing) is safe and may improve quality of life in
older people.
• Optimal medication management in older people requires a multidisciplinary approach to ensure the best
quality of life.

Practice points
Practice points References Grade
Assess a patient’s risk of adverse medication events and drug 1 Consensus-based
interactions, particularly if polypharmacy includes over-the-counter recommendation
medications or complementary and alternative medicines
Review all prescription medication following changes in comorbidity 1 Consensus-based
and progression of disease recommendation
Consider pre-planning medications when required for anticipated 7 Consensus-based
events from specific conditions (eg allergic reaction, angina, recommendation
asthma, chronic obstructive pulmonary disease, constipation,
diabetes, diarrhoea, dry eyes, nausea, pain,
skin rashes)
Dose forms and devices for administration of medicines may be of 1 Consensus-based
assistance to patients recommendation
2 RACGP aged care clinical guide (Silver Book) Part A. Medication management

Consider the patient’s requirements for end-of-life care 1 Consensus-based

recommendation
Wherever possible, use non-drug treatments either alone or as an 6 Consensus-based
adjunct to medication recommendation
Use the lowest effective maintenance dose when starting a patient 1 Consensus-based
on a new medication recommendation
Consider the changing pharmacokinetics in older people that can 6 Consensus-based
affect drug absorption, distribution, metabolism and excretion, and recommendation
adjust doses as appropriate

Introduction
Older people’s medication needs may be complex because of the high prevalence of disease and comorbidities (refer
to Part A. Multimorbidity). Optimal medication management for older people in residential aged care facilities
(RACFs) and the community involves a multidisciplinary and systematic approach with patients and/or their
representative, general practitioners (GPs), pharmacists, aged-care nurses, other RACF staff, health service
providers and allied health practitioners.
The Australian Pharmaceutical Advisory Council’s (APAC’s) Guiding principles for medication management in
residential aged care facilities (the Principles) builds on previous editions of guidelines developed under Australia’s
National Medicines Policy. It promotes safe, quality use of medicines and medication management in RACFs.1 The
Principles is intended to assist RACFs to:

• develop, implement and evaluate locally specific policies and procedures

• support those involved in assisting residents
• support residents in the medication management process.
It is essential that GPs working in RACFs are familiar with the 17 Guiding principles as listed in Table 1.

Table 1. APAC’s guiding principles1

Guiding principle Comments

Guiding principle 1. The residential aged care facility (RACF) should establish (or have direct access
Medication Advisory to) and use a Medication Advisory Committee to support the safe and effective
Committee management and quality use of medicines in the facility
Guiding principle 2. The RACF should ensure that current and accurate medicines information
Information resources resources are available to all residents, carers, staff and visiting healthcare
professionals
Guiding principle 3. The RACF should support informed and considered selection of all medicines
Selection of medicines used in the facility
Guiding principle 4. The RACF should support informed selection and safe use of complementary,
Complementary, alternative and self-selected non-prescription medicines used by residents
alternative and self-
selected non-
prescription medicines
Guiding principle 5. The RACF should develop policies and procedures for safe practice in nurse-
Nurse-initiated non- initiation of non-prescription medicines
prescription medicines
Guiding principle 6. The RACF should develop policies and procedures to guide the use and review of
Standing orders standing orders where these are used in the facility
Guiding principle 7. The RACF should ensure all residents have a current, accurate and reliable record
Medication charts of all medicines selected, prescribed and used, to support safe prescribing and
administration of medicines and effective communication of medicines information
between residents and their healthcare professionals, and between care settings
Guiding principle 8. The RACF and residents’ visiting healthcare professionals should ensure each
Medication review and resident’s medication management is reviewed regularly and as needed.
 RACGP aged care clinical guide (Silver Book) Part A. Medication management 3

medication Medication reconciliation processes should be used to ensure residents receive all
reconciliation intended medicines, and to reduce risk of errors in documentation when care is
transferred or new medicines are ordered
Guiding principle 9. The RACF should ensure that medicines supply is maintained for residents in
Continuity of medicines changed circumstances to reduce disruption of their access to needed medicines
supply
Guiding principle 10. The RACF should develop policies and procedures for the management of an
Emergency stock of emergency stock of medicines where this is used
medicines
Guiding principle 11. The RACF should ensure all medicines, including self-administered medicines,
Storage of medicines are stored safely and securely and in a manner that maintains the quality of the
medicine
Guiding principle 12. The RACF should ensure that unwanted, ceased or expired medicines are
Disposal of medicines disposed of safely to avoid accidental poisoning, misuse and toxic release into the
environment
Guiding principle 13. The RACF should support those residents who wish to administer their own
Self-administration of medicines as part of maintaining their independence. This should follow
medicines assessment and regular review of these residents’ capacity to self-administer
medicines safely
Guiding principle 14. The RACF should ensure that staff are appropriately qualified and authorised to
Administration of administer medicines, and that administration practices are monitored for safety
medicines by RACF and quality
staff
Guiding principle 15. The RACF should develop policies and procedures to guide dose administration
Dose administration aid, needs assessment, preparation, use, monitoring and quality assurance
aids
Guiding principle 16. The RACF should ensure that residents, their carers and staff administering
Alteration of oral dose medicines know which oral dose medicines can and cannot be altered in form,
forms such as by crushing or chewing and any special conditions relating to the
alteration or administration of specific medicines
Guiding principle 17. The RACF should regularly review and evaluate each area of medication
Evaluation of management for outcomes and take follow-up action where required
medication
management

Particular aspects of medication management for GPs to consider when working in RACF include:1

• efficient and effective partnership between patients, prescribing GPs, dispensing and accredited consultant
pharmacists and support staff (eg nursing staff, RACF staff, clinical care coordinator)
• assessing risks of adverse medication events and drug interactions, particularly if polypharmacy is combined with
over-the-counter medications, or complementary and alternative medicines (refer to Part A. Polypharmacy)
• regular reviews of prescribed medication following changes in comorbidity and progression of disease to optimise
medication use
• prescribing as required to cover anticipated events
• using appropriate dose forms and devices for administrating medicines
• requirements for end-of-life care (refer to Part A. Palliative and end-of-life care).
Medication management differs between residents in RACFs and older people in the community as, for the former
group, medications are administered by staff at the optimal times with few issues in compliance. In addition, regular
observation of residents in RACFs enables early recognition of medical conditions and monitoring of treatment goals.
4 RACGP aged care clinical guide (Silver Book) Part A. Medication management

Clinical context
All people have the right to give informed consent or refuse any medical intervention, including medication. It is
important to discuss treatment issues and ongoing care plans with patients and their relatives/carers or
representatives using language that can be easily understood.2 Prescribing principles for older people include the
following:1,2,3,4, 5,6

• Consider medication being taken by the patient on admission, including prescription, non-prescription and
complementary and alternative medication, and effect of prior adherence or non-adherence.
• Wherever possible, use non-drug treatments either alone or as an adjunct to medication in preference to
medication.
• New medications should follow a ‘start low, go slow’ approach; increase slowly according to tolerability and
response.
• Use the lowest effective maintenance dose.
• Select medications that are suitable for use in older people with minimal adverse effects.
• Be aware of changing pharmacokinetics in older people that can affect drug absorption, distribution, metabolism
and excretion, and adjust doses as appropriate.
• Check drug–drug, drug–disease and drug–food interactions using evidence-based references.
• Set monitoring protocols when appropriate.
• Prescribe the least number of medications, with the simplest dose regimens.
• Consider the patient’s functional and cognitive ability when prescribing.
• Consider medication adverse effects if there is a decline in physical or cognitive function.
• Prescribe suitable formulation of medications if a person experiences problems with swallowing.
• Involve patient and family regarding any significant changes in medication (eg deprescribing; refer to Part A.
Deprescribing).
• Regularly review treatment and cease medications if they are no longer appropriate or goals of management
change.
• If the patient is self-administering, regularly assess their ability to continue to manage their medication
administration and storage.
Prescribing medications include routine medications, as well as pre-planning medications when required for
anticipated events from specific conditions (eg allergic reaction, angina, asthma, chronic obstructive pulmonary
disease [COPD], constipation, diabetes, diarrhoea, dry eyes, nausea, pain, skin rashes).
The decision to prescribe medications should optimally be:

• evidence based
• made in the context of the patient’s medical and psychosocial condition, prognosis, quality of life and wishes
• made in the context that overuse, underuse and inappropriate use of medications are equally important quality of
care concerns.
The Australian and New Zealand Society for Geriatric Medicine (ANZSGM) has released a position statement on
Prescribing in older people that provides further details.7

In practice
In the RACF setting, medication orders are written on the RACF medication chart by qualified prescribers, taking into
account the needs and views of residents (or representatives), policies of the RACF, legislative requirements and
professional standards. The qualified prescriber is usually the resident’s GP, but may also be a locum or hospital
doctor, Hospital in the Home (HITH) prescriber, geriatrician or palliative care team member. In some situations,
registered dental practitioners or registered nurse practitioners may be able to prescribe medications.

It is necessary for GPs to work closely with RACF staff to regularly review and rewrite medication charts and
prescriptions to maintain a continuum of medication for residents. There is currently a transition from medication
charts to the national standard medication chart, and also to electronic chart prescribing in accordance with
mandatory legislative requirements.8
 RACGP aged care clinical guide (Silver Book) Part A. Medication management 5

APAC’s National guidelines to achieve continuity in medication management should be referenced when a resident
moves between different healthcare settings (eg hospital to RACF).7 The World Health Organization’s (WHO’s)
Medication safety in transitions of care provides further detailed information to improve safety in transition from
hospital to home or RACF.9

Residential medication management review

Under the sixth Community Pharmacy Agreement, Medicare requires contracts in order for accredited pharmacists to
undertake a Residential Medication Management Review (RMMR; Medicare Benefits Schedule [MBS] item number
903) in a particular RACF.10
RMMRs are services provided to permanent residents of Commonwealth-funded RACFs. The RMMR is conducted
by an accredited pharmacist when requested by a resident’s GP, and undertaken in collaboration with the resident’s
GP and appropriate members of the resident’s healthcare team. A comprehensive assessment is undertaken to
identify, resolve and prevent medication-related problems, and this assessment is provided to the resident’s GP. The
RMMR is recommended for each resident on admission and regularly reviewed thereafter when there is a
therapeutic need.

As of April 2020, pharmacists are able to undertake two additional follow-up reviews after the initial RMMR. Referrals
are no longer required by GPs and there is no MBS item number for follow-up reviews. Follow-up services should be
provided by an accredited pharmacist and fed back to the resident’s GP. The first follow-up interview should be
undertaken no earlier than one month and no later than nine months after the initial interview. If a second follow-up
interview is required, it should be undertaken no earlier than one month after the first follow-up interview and no later
than nine months after the initial interview.10

Quality Use of Medicines

The Quality Use of Medicines (QUM) program is a separate service provided by a registered or accredited
pharmacist, and focuses on improving practices and procedures as they relate to QUM in an RACF.10

Home Medicines Review

In the community, medication should be reviewed regularly to identify discrepancies between medicines being taken
and those prescribed. The initial Home Medicines Review (HMR) requires a GP referral. If follow-up services are
required, this should be undertaken by an accredited pharmacist. The first follow-up interview should be undertaken
no earlier than one month and no later than nine months after the initial interview. If a second follow-up interview is
required, it should be undertaken no earlier than one month after the first follow-up interview and no later than nine
months after the initial interview.12 The Home Medicines Review (HMR; MBS item number 900) is available for the
GP and pharmacists to assess optimal medication management.

Dispensing, storage and disposal

Pharmacists work closely with GPs to dispense and supply medication safely, and accredited consultant pharmacists
conduct medication reviews only on referral from a GP. All three can work closely as a team with the RACF staff to
supply the dispensed medications in a suitable form and ensure their safe handling at the facility.

The Pharmaceutical Society of Australia has developed standards for pharmacy services to residents, outlining the
following recommendations:13

• Maintain appropriate systems for the supply of medicines to the facility.

• Ensure medicines are delivered to the RACF in a timely manner.
• Ensure medicines are stored within the RACF in accordance with legislative and manufacturers’
storage requirements.
• Monitor stock medicines used in the RACF.
• Check medications brought into the RACF by new patients, as soon as practicable after admission, to
ensure consistency with currently prescribed medications.
• Conduct a comprehensive medication review of all residents at regular intervals and maintain
appropriate records.
• In consultation with medical practitioners, identify residents who may require therapeutic medication monitoring.
• Identify, monitor and document adverse medication events.
6 RACGP aged care clinical guide (Silver Book) Part A. Medication management

• Provide information on medicines that adequately meet the needs of the RACF.
• Provide an education program appropriate to the needs of the RACF.
• RACFs must have a mechanism in place for the disposal of returned, expired and unwanted medicines.

Administering medication
Medication can be administered by a registered nurse (RN), an endorsed enrolled nurse (EN) or a personal care
assistant (PCA) who is qualified to administer medication, or can be self-administered by the resident if they are
assessed to be competent to do so.1
Dose administration aids can be used to provide medications where an RN who is qualified to administer medications
is unavailable, and can be used to assist residents to self-administer. ‘Blister’ packaging systems or medication
sachets are packed and labelled by a pharmacist, and the medication is administered directly from the dose
administration aid to the resident. If the prescriber alters any medication order, the entire dose administration aid
must be returned to the supplying pharmacist for repackaging. RACF staff should refer to relevant state/territory
legislation for further information on dose administration aids. Older people in the community may administer from
original containers or use dose administration aids either packed by themselves, family members or the supply
pharmacy.

Modifying oral products

Many older people have difficulty swallowing tablets and capsules. Wherever possible, oral dose forms of medicines
should not be altered.1,2

Medications must not be crushed or altered without consultation with the pharmacist or drug information centre.
Altering the form of medication by crushing, cutting or dispersing may result in the risk of toxicity, reduced
effectiveness, gastrointestinal irritation, unacceptable presentation to residents in terms of taste or texture, or an
occupational health and safety issue to nursing staff.1,2
Details about the suitability for dispersion, crushing or cutting for people with difficulties swallowing or with enteral
feeding tubes are provided in The Society of Hospital Pharmacists Australia’s Don’t rush to crush.14 This resource is
available as a text or as part of Monthly Index of Medical Specialities (MIMS) or Australian Drug Information (AusDI)
as an additional subscription and should be used in conjunction with advice from a pharmacist.
Alterations in drug delivery should be recorded on the patient’s medication chart with the date reviewed, so that all
members of the healthcare team are aware of the new procedures. Each RACF is required to have a policy for the
administration of altered medications, and suitable techniques if the drug is approved for crushing.12

Review medication regimen

Difficulty in swallowing provides an opportunity to review the medication profile; before trying to cut, crush and/or
dissolve a tablet or capsule, consider: 2
• stopping medicines that are no longer necessary
• using an oral liquid
• using other available routes (eg rectal, topical, transdermal, parenteral) that may be appropriate
• changing to an alternative drug that is easier to give or has a liquid or dispersible preparation available.
If a resident has difficulties swallowing medicines, it can be assumed that they will also encounter difficulties with
food. Referral to a speech pathologist and dietitian may also be considered.
 RACGP aged care clinical guide (Silver Book) Part A. Medication management 7

Resources
GPs should have access to evidence-based information on prescribing medication, including the following:

• Australian medicines handbook:1 Provides a comparative, practical formulary covering medications marketed in
Australia
• AMH aged care companion (online):2 Particularly relevant for older people living in RACFs
• National Prescribing Service: A free service
• Australian Prescriber: An independent peer-reviewed journal providing critical commentary on drugs and therapeutics
• Veterans’ Mates publications
• Therapeutic Guidelines: Series of 15 texts reviewed by expert consensus groups at regular intervals
• Australian and New Zealand Society for Geriatric Medicine’s (ANZSGM’s) Position statements
• Quality use of medicines to optimise ageing in older Australians: Recommendations for a national strategic action
plan to reduce inappropriate polypharmacy
Production information and consumer medicines information guides are available from MIMS, AusDI, the Australian
Register of Therapeutic Goods (ARTG), and are included in most prescribing software. Prescribers should ensure
they are registered to receive regular Therapeutic Goods Administration (TGA) alerts (including any adverse event
reporting) and alerts on the monthly changes to the Pharmaceutical Benefits Scheme (PBS).
Prescribing guidelines and position statements are also available from many chronic disease organisations, including:

• National Heart Foundation

• National Asthma Council of Australia’s Australian asthma handbook
• Australian Lung Foundation
• The Royal Australian College of General Practitioners (RACGP) and Diabetes Australia’s General practice
management of type 2 diabetes
• The RACGP and Arthritis Australia’s Guideline for the management of osteoarthritis
• Osteoporosis Australia

References
1. Rossi S. Australian medicines handbook. Adelaide: Australian Medicines Handbook Pty Ltd, 2019. Available at www.amh.net.au
[Accessed 8 August 2019].

2. NPS MedicineWise. Medical info. Canberra: NPS MedicineWise, 2019. Available at www.nps.org.au [Accessed 8 August 2019].

3. Department of Veterans’ Affairs. Publications. Canberra: DVA, 2019. Available at www.veteransmates.net.au/academic-publications

[Accessed 8 August 2019].

4. Basger BJ, Chen TF, Moles RJ. Validation of prescribing appropriateness criteria for older Australians using the RAND/UCLA
appropriateness method. BMJ Open 2012;2:e001431.

5. The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers criteria for
potentially inappropriate medication use in older adults. J Am Geriatr Soc 2012;1:1–16.

6. Australian and New Zealand Society for Geriatric Medicine. Prescribing in older people. Sydney: ANZSGM, 2018. Available at
www.anzsgm.org/documents/PositionStatementNo29PrescribinginOlderPeople26March2018.pdf [Accessed 8 August 2019].

7. Australian Pharmaceutical Advisory Council. Guiding principles to achieve continuity in medication management. Canberra: APAC, 2005.

8. Australian Commission on Safety and Quality in Health Care. National residential medication chart. Sydney: ACSQHC, 2018.
Available at www.safetyandquality.gov.au/our-work/medication-safety/nrmc [Accessed 8 August 2019].

9. World Health Organization. Medication safety in transitions of care. Geneva: WHO, 2019. Available at
www.who.int/patientsafety/medication-safety/TransitionOfCare.pdf?ua=1 [Accessed 8 August 2019].

10. Australian Department of Health, Pharmacy Programs Administrator. Program Rules: Residential Medication Management Review.
Canberra: Australian Department of Health, 2020 [Accessed 30 October 2020]
11. 6th Community Pharmacy Agreement. Residential medication management review and QUM. Canberra: 6CPA, 2018. Available at
http://6cpa.com.au/medication-management-programs/residential-medication-management-review [Accessed 8 August 2019].

12. Australian Department of Health, Pharmacy Programs Administrator. Program Rules: Home Medicines Review. Canberra:
Australian Department of Health, 2020 [Accessed 30 October 2020]

13. Pharmaceutical Society of Australia. Professional practice standards. Canberra: PSA, 2017. Available at www.psa.org.au/practice-
support-industry/professional-practice-standards [Accessed 8 August 2019].

14. Burridge N, Symons K (eds). Don’t rush to crush. Melbourne: The Society of Hospital Pharmacists of Australia, 2019. Available at
www.shpa.org.au/dont-rush-to-crush-2nd-edition [Accessed 8 August 2019].
 RACGP aged care clinical
guide (Silver Book)
5th edition
Part A. Polypharmacy

General principles
• The higher prevalence of disease states in older people means they take many medicines.
• The risk of adverse drug events and drug interactions increase with the number of medicines taken.
• Polypharmacy is associated with suboptimal prescribing.
• Good practice requires regular review of a patient’s medicines, medical conditions and comorbidities.

Practice points
Practice points References Grade
Only use medicines associated with strong evidence of benefit 11 Consensus-based
when indicated, and cease those with questionable or no evidence recommendation
of efficacy
Identify inappropriate prescribing in older people using the Beers 12 Various, refer to Table 2
Criteria, with varying levels of evidence for different patient groups in reference 12
All prescribing criteria have limitations and do not substitute for 9 Consensus-based
good clinical decision making; however, they are prompts for recommendation
potentially inappropriate prescribing
Review the medication of all older people (ie prescribed, over-the- 3, 4 Consensus-based
counter, complementary and alternative medicines) and attempt to recommendation
deprescribe, particularly for those who are vulnerable to the
adverse effects of medication
Consider indications, therapeutic aims, dose, efficacy, safety and 4 Consensus-based
ability to use devices as part of the patient’s medication review recommendation
Calculate renal function and consider hepatic impairment for all 4 Consensus-based
patients, especially those with polypharmacy recommendation
2 RACGP aged care clinical guide (Silver Book) Part A. Polypharmacy

Check for drug interactions, side effects and adverse drug reactions 4 Consensus-based
recommendation
Medicines (including complementary and alternative medicines) – Consensus-based
must be written on the patient’s medication chart, even if the recommendation
medicines are being self-administered

Introduction
A literature search of medication and safety in Australia shows that medication-related hospital admissions are estimated
to be 2–3% of all hospital admissions, which is about 250,000 hospital admissions per year at a cost of $1.4 billion. 1
Among people aged ≥65 years with medical or surgical admissions, 55% were on a potentially inappropriate medicine and
6% of all admissions were due to the potentially inappropriate medicine.1

Medicine use in older people involves a complex balance between managing disease and avoiding medicine-related
problems. The higher prevalence of disease in older people with multiple comorbidities means they take more medicines,
which increases the risk of adverse drug effects and interactions (refer to Part A. Multimorbidity). 2
The International Group for Reducing Inappropriate Medication Use and Polypharmacy (IGRIMUP) has produced a
position statement and a list of 10 recommendations (Box 1) for action and 12 recommendations for research. 3 This
transition requires a shift in medical education, research and diagnostic framework, and re-examination of the measures
used as quality indicators.

Box 1. Ten recommendations for action of the International Group for Reducing Inappropriate Medication Use and
Polypharmacy3

1. Review the medication of all older people with an eye to deprescribing, particularly those who are vulnerable to
the adverse effects of medication.
2. Before initiating a potentially ‘appropriate’ medication, consider the validity of the evidence based on patient
characteristics and preferences.
3. Consider each medication for potential withdrawal, extending beyond standardised lists.
4. Employ mixed implicit and explicit approaches to polypharmacy.
5. Address the underrepresentation of older patients in clinical trials.
6. Acknowledge and address commercial influences on polypharmacy: trial results should not be implemented in
older adults unless access to all available patient-level data is provided. Appropriate outcome measures should
be required before licensing indications that include older populations.
7. Medical education needs a stronger focus on inappropriate medication use and polypharmacy.
8. Medical training should review methods to stop treatments and provide equal attention to drug side effects and
benefits.
9. When patients have multimorbidity, the single disease model should be spurned. The single disease approach
with adherence to clinical guidelines for each illness makes polypharmacy and inappropriate medication use
inevitable.
10. Decisions in older complex patients should routinely consider expected survival and quality of life, giving the
highest priority to patient/family preferences.

Australia has now adopted the Quality use of medicines to optimise ageing in older Australians: Recommendations for a
National Strategic Action Plan to Reduce Inappropriate Polypharmacy (National Plan), which currently has global action
statements to increase awareness of polypharmacy. 4 The National Plan is relevant to consumer, professional, academic,
government and policymaking organisations to:

• raise awareness of the significant challenges polypharmacy creates for individuals and society
• provide an integrated cohesive National Plan for a wide spectrum of stakeholders and settings (national and/or local
organisations) to use when designing their own plans for reducing polypharmacy and optimising medicines use in their
population
• highlight the activities and resources needed as part of a cohesive framework to inform funding and policy decisions.
 RACGP aged care clinical guide (Silver Book) Part A. Polypharmacy 3

Clinical context
Polypharmacy is usually defined as the use of five or more drugs, including prescription, over-the-counter, and
complementary and alternative medicines. 5,6 The more medicines a patient takes, the harder it may be to obtain an
accurate medication history, which impedes informed medication review and prescribing (refer to Part A. Medication
management). The incidence of adverse drug reactions increases with the number of medicines used. 7 Polypharmacy may
be a barrier to adherence because of the associated complex medication regimens, increased risk of adverse drug events
and high medication costs.

Polypharmacy is associated with suboptimal prescribing. The more medicines a patient is exposed to, the more likely they
are to be prescribed inappropriately and the poorer the patient's overall function. In addition, the more medications a
person takes, the more likely they are not prescribed one or more indicated medicines. 8
The ‘prescribing cascade’ – where one medicine is begun to treat the adverse effects of another – can also contribute to
the number of medicines taken.5,9,10

Risks from multiple medicines include adverse effects, hospitalisations, functional impairment, geriatric syndromes
(eg confusion, falls, incontinence, frailty) and mortality. 11
Appropriate prescribing comprises the use of medicines associated with strong evidence of benefit when indicated,
monitoring and dose adjustments while using, and ceasing those with questionable or no evidence of efficacy. There are
many tools used to reduce polypharmacy and inappropriate prescribing.

In practice
The Beers Criteria is one of the more commonly used resources to identify inappropriate prescribing. 12 The 2015 American
Geriatrics Society’s (AGS’s) Beers Criteria includes a list of potentially inappropriate medications that should be avoided in
older people, each to their various levels of evidence (refer to Table 2 in reference 10). The criteria include medicines that
should be avoided, or have their dose adjusted, based on the patient’s kidney function and select drug–drug interactions
documented to be associated with harms in older people.12 This criteria was further updated in 2019. 13
Other common criteria that could be considered include:

• McLeod Criteria 14
• Screening Tool to Alert to Right Treatment (START); Screening Tool of Older People’s Prescriptions (STOPP) 15
• Medication Appropriateness Tool for Comorbid Health conditions during Dementia (MATCH-D) 16
• Australian Inappropriate Medication Use and Prescribing Indicators tool, plus the MATCH-D for people with dementia.9
All prescribing criteria have limitations and do not substitute for good clinical decision making; however, they are an alert to
potentially inappropriate prescribing.
Box 2 lists some of the medicines where caution must be exercised when prescribed to older people. This information is
based on the Beers and McLeod revised criteria, and has been further revised to ensure its relevance to medicines
available in Australia.

Box 2. Medicines to be used with caution in older people2,9,12,13

• Amiodarone
• Anticholinergic agents
• Antihistamines (first generation)
• Antipsychotics for behavioural and psychological symptoms of dementia
• Aspirin for primary prevention for those aged >80 years
• Benzodiazepines
• Diuretics
• Fluoxetine
• Methyldopa
• Nitrofurantoin
4 RACGP aged care clinical guide (Silver Book) Part A. Polypharmacy

• Nonsteroidal anti-inflammatory drugs (NSAIDs), including cyclooxygenase-2 (COX-2) inhibitors

• Tricyclic antidepressants

Medication review
While the traditional medicine review process typically involved cross-referencing medicines used with current diagnoses,
a more sophisticated version of this process critically reviews the medicines and associated diagnosis, giving less
emphasis to diagnoses that are no longer relevant (refer to Part A. Medication management). Known as undiagnosis, this
process facilitates the withdrawal of corresponding medicines used to manage those conditions. Systematically reviewing
diagnoses regularly and the associated medicine management strategies could reduce prescribing. The novel ERASE
mnemonic can help clinicians: 17

• Evaluate diagnoses to consider

• Resolved conditions
• Ageing normally
• Selecting appropriate targets to
• Eliminate unnecessary diagnoses and their corresponding medicines
Regular medication review in older people is important to identify those at high risk of harm from polypharmacy, monitor
efficacy, and reassess the need for specific medicines (refer to Part A. Medication management). The review should
consider ongoing treatments in terms of current goals of care, patient preferences and life expectancy.

The assessment should:4

• obtain an accurate and current history

– review all medications prescribed, including over-the-counter and complementary medicines
– consider indication, therapeutic aims, dose, efficacy, safety and (where appropriate) ability to use devices
– calculate renal function and consider hepatic impairment
– check for drug interactions, side effects and adverse drug reactions
• match the medicines to medical conditions and treatment goals. These will change with ageing and may involve
undiagnosis. Identify discrepancies between medicines being taken and those prescribed, including pro re nata (PRN)
medicines
• assess physical and cognitive function
• evaluate any medicines-related problems, monitoring required, and untreated conditions
• reassess goals of care.
In the residential aged care facility (RACF) setting, the list of medicines being taken by the patient must be written on the
medication chart, even if the medicines are being self-administered. Complementary and alternative medicines must be
approved, checked for safety and written up by the treating general practitioner (GP). Consider a Residential Medication
Management Review (RMMR; Medicare Benefits Schedule [MBS] item number 903), 18 which may be helpful. A Home
Medicines Review (HMR; MBS item number 900) 19 should be considered in the home environment to ensure a correct
current list of all medications being taken, adherence, and to identify medication-related problems.

References
1. Pharmaceutical Society of Australia 2019. Medicine safety: Take care. Canberra: PSA, 2019.

2. Rossi S (Ed). AMH Aged Care companion. Adelaide: Australian medicines handbook Pty Ltd, 2018. Available at www.amh.net.au [Accessed
8 August 2019].

3. Magin D, Bahat G, Golomb BA, et al. International Group for Reducing Inappropriate Medication Use & Polypharmacy (IGRIMUP): Position
statement and 10 recommendations for action. Drugs Aging 2018;35(7):575–87.

4. University of Sydney. Quality use of medicines. Sydney: UoS, 2018. Available at http://sydney.edu.au/medicine/cdpc/resources/quality-use-of-
medicines.php [Accessed 8 August 2019].

5. Hilmer SN. Editorial – The dilemma of polypharmacy. Aust Prescr 2008;31:2–31. Available at www.nps.org.au/australian-
prescriber/articles/the-dilemma-of-polypharmacy [Accessed 8 August 2019].

6. Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC Geriatr 2017;17(1):230.
 RACGP aged care clinical guide (Silver Book) Part A. Polypharmacy 5

7. Hanlon JT, Pieper CF, Hajjar ER, et al. Incidence and predictors of all and preventable adverse drug reactions in frail elderly persons after
hospital stay. J Gerontol A Biol Sci Med Sci 2006;61(5):511–15.

8. Beer C, Hyde Z, Almeida OP, et al. Quality use of medicines and health outcomes among a cohort of community dwelling older men:
An observational study. Br J Clin Pharmacol 2011;71(4):592–99.

9. NPS MedicineWise. Older, wiser, safer: Promoting safe use of medicines for older Australians. Canberra: NPS MedicineWise, 2013.

10. Kalisch LM, Caughey GE, Roughead EE, Gilbert AL. The prescribing cascade. Aust Prescr 2011;34:162–66. Available at
www.nps.org.au/australian-prescriber/articles/the-prescribing-cascade [Accessed 8 August 2019].

11. Turner JP, Jamsen KM, Shakib S, Singhal N, Prowse R, Bell JS. Polypharmacy cut-points in older people with cancer: How many medications
are too many? Support Care Cancer 2016;24(4):1831–40.

12. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially
inappropriate medication use in older adults. J Am Geriatr Soc 2012;1:1–16.

13. American Geriatrics Society 2019 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially
inappropriate medication use in older adults. J Am Geriatr Soc 2019. doi: 10.1111/jgs.15767. [Epub ahead of print].

14. McLeod PJ, Huang AR, Tamblyn RM, Gayton DC. Defining inappropriate practices in prescribing for elderly people: A national consensus
panel. Can Med Assoc 1997;156:385–91.

15. Gallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D. STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool
to Alert doctors to Right Treatment) – Consensus validation. Int J Clin Pharmacol Ther 2008;46:72–83.

16. Page AT, Potter K, Clifford R, McLachlan AJ, Etherton‐Beer C. Medication appropriateness tool for co‐morbid health conditions in dementia:
Consensus recommendations from a multidisciplinary expert panel. Intern Med J 2016;46(10):1189–97.

17. Page A, Etherton-Beer C. Undiagnosing to prevent overprescribing. Maturitas 2019;123:67–72.

18. MBS Online. Medicare Benefits Schedule – Item 903. Canberra: Department of Health, 2019. Available at
www9.health.gov.au/mbs/fullDisplay.cfm?type=item&qt=ItemID&q=903 [Accessed 22 July 2019].

19. MBS Online. Medicare Benefits Schedule – Item 900. Canberra: Department of Health, 2019. Available at
www9.health.gov.au/mbs/fullDisplay.cfm?type=item&qt=ItemID&q=900 [Accessed 22 July 2019].
 RACGP aged care clinical
guide (Silver Book)
5th edition
Part A. Dementia

General principles

• Dementia affects a range of cognitive and physical functions, including memory, ability to initiate action,
social function, activities of daily living and emotional control.

• Dementia is a chronic progressive disease that results in death.

• Diagnosis should include cognitive function testing, and exclusion of common differential diagnoses
including delirium due to physical illness, depression and medication side effects; it is important to assess
functional capacity, which is impaired in dementia.

• There is a range of anti-dementia medications available that may provide some modest delay in progression
of symptoms.

• The mainstay of management is support of the person and their carers in maintaining dignity and
independence as much as possible with non-pharmacological management.

• Behavioural and psychological symptoms of dementia, also known as responsive behaviours such as
agitation, may also be assisted by non-pharmacological management.

• Short-term prescription of antidepressants (eg selective serotonin reuptake inhibitors [SSRIs]) may have
a role.

Practice points
Practice points References Grade
Use the Diagnostic and statistical manual of mental disorders, fifth 2 Consensus-based
edition (DSM-5) to assist with the diagnostic criteria of dementia recommendation
Apply a cognitive function test, and exclude depression, physical 1, 6 Consensus-based
disorders and possible effects of medications before making a recommendation
diagnosis of dementia
2 RACGP aged care clinical guide (Silver Book) Part A. Dementia

Conduct pathology tests to exclude a medical cause of the patient’s 1 Consensus-based

cognitive decline recommendation
Conduct imaging to exclude brain tumour or other rare physical 1 Consensus-based
brain pathology (eg chronic subdural haematoma) recommendation
Assess for depression as it may mimic dementia (ie 12 Consensus-based
pseudodementia), and may also accompany dementia recommendation
Undertake a full and comprehensive medication review to exclude 15 Consensus-based
medications that may be affecting brain function recommendation
Conduct a functional assessment as a dementia diagnosis cannot 16 Consensus-based
be made unless there is interference with function recommendation
Regularly review a patient’s functional capacity 1 Consensus-based
recommendation
Communicate the diagnosis of dementia using a gradual and 1 Consensus-based
individualised approach recommendation
Consider a supported approach for more complex decision making 21 Consensus-based
recommendation
Three acetylcholinesterase inhibitors are recommended as options 1 Consensus-based
for managing the symptoms of mild-to-severe Alzheimer’s disease, recommendation
Parkinson’s disease dementia, Lewy body dementia, vascular
dementia or mixed dementia:

• donepezil

• rivastigmine

• galantamine

Be aware of adverse reactions, side effects and interactions 1 Consensus-based

between medications recommendation

Introduction
Dementia is a clinical syndrome that is caused by a number of underlying diseases. 1 It may be associated with
disorders as diverse as Parkinson’s disease and multiple sclerosis, and may be classified into a number of discrete
types, including the following four main types (or a mix of the four):

• Alzheimer’s disease

• vascular dementia

• frontotemporal dementia

• dementia with Lewy bodies

The Diagnostic and statistical manual of mental disorders, fifth edition (DSM-5) refers to dementia under the heading
of ‘Major neurocognitive disorder’. The diagnostic criteria for dementia under DSM-5 include the following: 2

• Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains
(ie complex attention, executive function, learning and memory, language, perceptual-motor or social cognition –
the role of cognition in understanding and responding appropriately to social interactions) based on
– concern of the individual, a knowledgeable informant or the clinician that there has been a significant decline
in cognitive function
– a substantial impairment in cognitive performance, preferably documented by standardised
neuropsychological testing or, in its absence, another quantified clinical assessment.

• The cognitive deficits interfere with independence in everyday activities (ie at a minimum, requiring assistance
with complex instrumental activities of daily living such as paying bills or managing medications).

• The cognitive deficits do not occur exclusively in the context of a delirium.

 RACGP aged care clinical guide (Silver Book) Part A. Dementia 3

• The cognitive deficits are not better explained by another mental disorder (eg major depressive disorder,
schizophrenia).
The implications for general practitioners (GPs) with the DSM-5 definition is that dementia may present with a
number of cognitive changes apart from memory problems, including decline in planning, organisation and social
cognition, and not involving memory. This may make it more challenging to diagnose dementia, especially in younger
patients.
The clinical picture should elicit any potential interference with activities of daily living, and GPs should monitor these
as the patient’s condition deteriorates by directly questioning the patient and talking to their carers. It is also important
to ensure that functions related to the self-management of chronic disease (eg self-medication with asthma puffers)
are maintained. GPs should be aware that some sort of cognitive function test should be applied (refer to Cognitive
function test), and a diagnosis should not be made until depression, physical disorders (eg electrolyte disturbance,
brain tumour) and the possible effects of medications are excluded.

Clinical context
The rate of dementia overall is 10% in those aged >75 years. Dementia is common in residents in residential aged
care facilities (RACFs), and the rates of prevalence are often quoted to be above 50%. 3 However, 70% of people with
dementia live in the community.
In the community, the spectrum of dementia is more at the mild-to-moderate level, where a few people with severe
dementia in the community are cared for by families. Many people with dementia will enter RACFs for respite or long-
term care several years after onset, when they require additional support for impairment in activities of daily living or
behavioural and psychological symptoms of dementia (BPSD; refer to Part A. Behavioural and psychological
symptoms of dementia).

Dementia and BPSD can have a significant physical and emotional effect on the patient, families and carers. The
process of moving to an RACF can be difficult, and requires understanding and support. 4 Some older people may
develop dementia while living in an RACF. Therefore, GPs are likely to see residents with the full spectrum of
dementia.
There are risks associated with making a dementia diagnosis, including the possibility of an adverse emotional
reaction from the patient and/or their family. However, there are also benefits associated with making a dementia
diagnosis, including:

• access to additional medications that require a formal diagnosis

• access to services that may enhance independence

• an understanding by the patient, family and staff that this patient has a chronic and terminal deteriorating
condition, and will require increasing support

• support from Dementia Australia and other organisations for the person with dementia, their family and carers
with strategies to live positively with dementia and compensate for deficits

• better management of medications and life decisions

• preparing for transition from driving

• preparation of the family for the patient’s ongoing cognitive deterioration, so that legal issues (eg will, power of
attorney for financial affairs, documents to support designated people to make health-related decisions, advance
care directives) can be attended while the person still has capacity

• communication of the diagnosis in transitions of care (eg hospitalisation) so that appropriate expectations and
action for care can be taken (eg the increased possibility of delirium postoperatively will require additional
nursing care).

In practice
Dementia is an insidious process, which usually starts while the person is living in the community. At this stage, it
does not readily reveal itself in the GP’s office. However, in order to provide support for the person living with
dementia and their family, and to avoid health, safety and other problems caused by functional decline, it is important
that this diagnosis is made earlier rather than later.
4 RACGP aged care clinical guide (Silver Book) Part A. Dementia

The RACF setting in itself speaks to a population that is not managing at home for one reason or other, and rates of
cognitive impairment in RACF settings are high. Talking to the patient may reveal changes in memory and other
cognitive deficits that should not simply be attributed to old age. Family and professional carers may also cast light on
cognitive deficits. Different types of dementia have different patterns of cognitive change. Refer to Box 1 on the
typical characteristics of cognitive impairment in early dementia with different causes.

Box 1. Typical characteristics of cognitive impairment in early dementia with different causes 5

• Early Alzheimer’s dementia is an insidious process of gradual cognitive decline that particularly affects the ability
to store new memories.

• Early vascular dementia is classically a ‘subcortical’ picture, with general slowing of mental processing, and can
be more varied in presentation than Alzheimer’s disease, with scattered changes across multiple cognitive
functions.

• Lewy body dementia tends to affect visuospatial and attention functions early in the disease process, and may
be accompanied by fluctuating confusion, visual hallucinations, Parkinsonism and rapid eye movement sleep
behaviour disorder.

• Frontotemporal dementia tends to affect executive and language function early in the disease process, and thus
usually presents with behavioural, language or personality changes.

Diagnosing dementia
It has been noted that GPs are not comfortable with diagnosing dementia themselves; however, in rural and remote
communities, and in the RACF setting, it may be difficult to access a specialist. In any case, whether or not the GP is
intending to refer on for a presumptive diagnosis, the following six steps should be included in consultation with the
patient and family:

• Step 1. Cognitive function test

• Step 2. Pathology tests

• Step 3. Imaging

• Step 4. Assessment for depression

• Step 5. Medication review

• Step 6. Functional assessment

Cognitive function test

The Royal Australian College of General Practitioners’ (RACGP’s) Guidelines for preventive activities in general
practice (Red Book) recommends the following cognitive function tests for the diagnosis of dementia: 6

• Standardised Mini-Mental State Examination (SMMSE) 7

• General Practitioner assessment of Cognition (GPCog) 8

• Clock drawing test 9

• Rowland Universal Dementia Assessment Scale (RUDAS; for detection of dementia across cultures) 10

• Kimberley Indigenous Cognitive Assessment (KICA) tool as a component of dementia assessment for Aboriginal
and Torres Strait Islander peoples living in remote areas 11

• Modified KICA, which may be used as a component of dementia assessment in more urban Aboriginal and Torres
Strait Islander peoples
As noted in the Red Book, the Mini-Mental State Examination (MMSE) is the most widely used and evaluated scale.
However, it is now copyrighted, and it should be replaced by the SMMSE. Cognitive function tests may be best
undertaken by the patient’s multidisciplinary team, which can include GPs, nurses, RACF staff, other specialist
medical practitioners, allied health professionals, family and carers.
 RACGP aged care clinical guide (Silver Book) Part A. Dementia 5

Pathology tests
Pathology tests should be conducted to exclude a medical cause of the patient’s cognitive decline. These should
include:1

• routine haematology

• biochemistry, including electrolytes

• calcium

• glucose

• renal and liver function tests

• thyroid function test

• B12 and folate levels.

Syphilis serology and human immunodeficiency virus (HIV) testing may be considered in specific cases.
Abnormalities should be investigated and treated as fully as possible before a dementia diagnosis can be made.

Imaging
Imaging should be conducted to exclude brain tumour or other rare physical brain pathology (eg chronic subdural
haematoma). Imaging (eg chest X-ray) may also be necessary to exclude chest pathology causing delirium.1

Assessment for depression

It is important to note that depression may mimic dementia (ie pseudodementia), and it may also accompany
dementia. A trial of antidepressants or talking treatment (eg those available from a psychologist) may be warranted.
Note also that antidepressants do not work well for depression in the presence of dementia, although they may be
helpful for agitation. 12
Of the antidepressants, selective serotonin reuptake inhibitors (SSRIs) are commonly recommended for patients with
dementia. Of the SSRIs, citalopram is regarded as being the most effective for the management of dementia.1 Start
with half the usual adult dose and increase as tolerated by the older person. Assess serum sodium after a fortnight as
hyponatremia is common. It is important to reassess the patient for a treatment response at four to six weeks. 13, 14
Strongly anticholinergic antidepressants (eg tricyclics) should be avoided because of their adverse effect on
cognition.
Refer to Part A. Mental health for more information.

Medication review
A full and comprehensive medication review needs to be undertaken to exclude medications that may be affecting
brain function. Psychotropics, medicines for urinary incontinence (refer to Part A. Urinary incontinence) and
anticholinergics are common culprits; however, a pharmacist may find that a combination of other medications (eg
antihistamines) may also be contributing. 15 Deprescribing should be undertaken if possible, and before a dementia
diagnosis is made (refer to Part A. Deprescribing). It is vital to do this slowly and monitor for adverse effects.
Refer to Part A. Medication management for more information.

Functional assessment
A dementia diagnosis cannot be made unless there is interference with a person’s function. Functional decline will
occur if dementia is present, although this is sometimes difficult to distinguish from physical decline and may be
subtle (eg loss of executive function, associated apathy).16
If the person still presents with symptoms of dementia following treatment of any treatable abnormalities, the
diagnosis of dementia should be considered.
Table 1 includes a comparison of the clinical features of delirium, dementia and depression.
6 RACGP aged care clinical guide (Silver Book) Part A. Dementia

Table 1. Comparison of the clinical features of delirium, dementia and depression 16

Reproduced with permission from Bridges-Webb C, Wolk J. Care of patients with dementia in general practice guidelines. Sydney: The
Royal Australian College of General Practitioners and NSW Health, 2003.
 RACGP aged care clinical guide (Silver Book) Part A. Dementia 7

Communicating the diagnosis

Like all medical bad news, communicating the diagnosis, or possibility, of dementia can be difficult. A gradual and
individualised approach is recommended.1 If the person does not want to know the diagnosis, this should be
respected. Family are usually keen to know, and the GP should take time to talk to them as well with the consent of
the patient.

Ongoing management
Apart from diagnostic assessments, a number of other assessment steps are required, and many of them will need to
be regularly reviewed.

Functional capacity
Functional capacity should be regularly reviewed, and steps should be taken to support this. An enablement
approach may assist with this objective, in which the person with dementia is enabled to perform activities if given the
appropriate supports. Examples include:

• person to accompany on activities (eg golf to keep score), or change of duties or better supervision to allow
continued employment

• organising a family member to pay the grocery bills so that shopping can be continued without concerns about
counting out money or remembering PIN numbers

• appropriate walking aids (including regular review of footwear) 17

• signage to enable them to find the toilet easier 18

• modification of eating utensils and food to allow for self-feeding 19

• regular reminders to enable them to structure their day. 20

In RACFs, staff input for these tasks can be very helpful, but does require training and takes time. The GP may be in
a position to advocate for such training, which may be provided through Dementia Support Australia and is free to the
RACF. In the community, psychosocial support provided by Dementia Australia and other local initiatives may assist
with maintaining physical, emotional and social functioning.

Behavioural and psychological symptoms

It is important to note that these symptoms may be subtle (eg apathy). Refer to Part A. Behavioural and psychological
symptoms of dementia for more information.

Decision-making capacity
A dementia diagnosis in itself is not a reason to assume the patient lacks the capacity for many decisions. A person
with dementia may not be able to decide on their share trading, but may be more than capable of deciding which
program they wish to watch on television. A supported decision-making approach may be used for more complex
decisions (eg move to a higher level of care). 21
There are strong arguments for supporting the ‘dignity of risk’ in some cases. For example, a person in the
community may wish to leave the bathroom window open a little so the cat can get in, and the comfort provided by
the pet needs to be weighed against the more remote risk of a break-in.

Physical comorbidities
There are a number of common physical comorbidities of dementia that are often not appreciated, including: 22

• impaired vision – dementia affects the visual cortex and not eye problems per se

• falls – dementia impairs the ability to appreciate physical surroundings (refer to Part A. Falls)

• weight loss – not due to lack of food intake

• poor oral health – not necessarily due to a lack of teeth cleaning

8 RACGP aged care clinical guide (Silver Book) Part A. Dementia

• seizures – minor absences or more major seizures; these occur in up to 10% of people living with dementia.
GPs should be aware of these common physical comorbidities and take steps to treat them if possible. A special diet
may be necessary, especially if oral health is poor. Fall prevention measures should be instituted, and the
environment should be uncluttered and clearly labelled if possible. Discussion with family members, or staff if in an
RACF about these issues may be helpful.
It should be noted that there is growing evidence that good nutrition (eg Mediterranean diet), regular exercise and
social contact may alleviate symptoms of dementia and slow progression (secondary prevention). 23 As noted in the
UK’s National Institute for Health and Care Excellence (NICE) guidelines, cognitive stimulation may also be helpful. 24
Family should be encouraged to incorporate these into the daily routine. Discussion with staff should take place to
encourage the resident to participate in some of these recommended activities when they are available.
It is important that other geriatric syndromes are recognised and managed appropriately, as residents with dementia
often may not report specific problems during routine care. The RACF setting provides opportunities for carefully
targeted prevention and intervention programs for care of common conditions in people with dementia, 25,26, 27
including:

• routine assessment of swallowing difficulties

• monitoring verbal and non-verbal pain behaviours

• prompting patients to visit the toilet on a regular basis.

In the community, speech pathologists often have an underestimated role in relation to swallowing and
communication techniques. Family need support and education in relation to these interventions.

Palliative care
GPs have an important role in the palliative care of people with dementia, including in making decisions about when
the principles of palliation should apply. Often the question ‘Would you be surprised if this person died within a year?’
may assist in this process. This decision should be made with the family and other carers, and informed if possible by
an advance care directive. Discussion should occur about whether the family and the person would wish to die at
home, and how best to support this if possible.
Refer to Part A. Palliative and end-of-life care for more information.

Medication
The National Health and Medical Research Council’s (NHMRC’s) Clinical practice guidelines and principles of care
for people with dementia recommends any one of three acetylcholinesterase inhibitors for managing the symptoms of
mild-to-severe Alzheimer’s disease, Parkinson’s dementia, Lewy body dementia, vascular dementia or mixed
dementia:1

• donepezil

• rivastigmine

• galantamine.
These should not be used for frontotemporal dementia because of severe side effects, and may exacerbate BPSD in
this condition.
Initial prescription of acetylcholinesterase inhibitors on the Pharmaceutical Benefits Scheme (PBS; only available on
the PBS for Alzheimer’s disease) must be done in consultation with a specialist physician geriatrician or psychiatrist.
To continue the use of these medications, there needs to be evidence of clinical improvement during the first six
months of therapy.
A Cochrane Review has shown some evidence of benefit of acetylcholinesterase inhibitors in managing the
symptoms of dementia. 28 In particular there is evidence that acetylcholinesterase inhibitors improve cognitive
function, function in activities of daily living, BPSD, and possibly quality of life and caregiver burden.
Acetylcholinesterase inhibitors do not alter the course of the disease, which is one of progressive decline.

These medications are associated with a number of adverse reactions in people with dementia, and should be
closely monitored. The adverse reactions include:1

• nausea

• vomiting

• diarrhoea
 RACGP aged care clinical guide (Silver Book) Part A. Dementia 9

• dizziness

• increased urinary incontinence and frequency

• falls

• muscle cramps

• weight loss

• anorexia

• headache

• insomnia.
Heart block is rare, but is a serious potential adverse event; an electrocardiography should therefore be performed
prior to prescribing the medication. Thyroid function may need checking. GPs should be aware that increased
incontinence may follow, and watch for a prescribing cascade. In particular, anticholinergic medications (eg for
incontinence) should be avoided or deprescribed, as they counteract the effects of the cholinesterase inhibitors
(refer to Part A. Deprescribing). 29
Memantine is an option for those with moderate-to-severe Alzheimer’s disease, and may also have efficacy for
moderate-to-severe vascular dementia. 30 It is an N-methyl-D-aspartate (NMDA) receptor antagonist, which may be
prescribed under authority for moderately severe Alzheimer’s disease and continued if a clinically meaningful
response is shown.
There are case reports of adverse drug withdrawal reactions, including worsening of cognition, so a decision to cease
these medications should involve a gradual withdrawal, and regular review (eg every four weeks).

References
1. National Health and Medical Research Council. Clinical practice guidelines and principles of care for people with dementia. Canberra:
NHMRC, 2016. Available at http://sydney.edu.au/medicine/cdpc/documents/resources/Dementia-Guideline-Recommendations-WEB-
version.pdf [Accessed 12 August 2019].

2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th edn. Washington DC: APA, 2013.

3. Dementia Australia and Australian Institute of Health and Welfare. Dementia statistics. Canberra: Healthdirect, 2018. Available at
www.healthdirect.gov.au/dementia-statistics [Accessed 12 August 2019].

4. Scherer S. Getting ACROSS Dementia: A dementia management resource for general practice. Melbourne: Southcity GP Services
and Alzheimer’s Association Victoria, 2003.

5. Curran E, Chong T, Lautenschlager N. Dementia: How to reduce the risk and impact. Med Today 2018;19(9):14–23. Available at
https://medicinetoday.com.au/system/files/pdf/MT2018-09-14-CURRAN_0.pdf [Accessed 12 August 2019].

6. The Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. 9th edn. East
Melbourne, Vic: RACGP, 2016. Available at www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-
racgp-guidelines/red-book/preventive-activities-in-older-age/dementia [Accessed 12 August 2019].

7. Independent Hospital Pricing Authority. Standardised Mini-Mental State Examination (SMMSE). Canberra: IHPA, 2018. Available at
www.ihpa.gov.au/what-we-do/standardised-mini-mental-state-examination-smmse [Accessed 12 August 2019].

8. Brodaty H, Pond D, Kemp NM, Luscombe GS, Harding L. The GPCOG: A new screening test for dementia designed for general
practice. J Am Geriatr Soc 2002;50(3):530–34.

9. Kirby M, Denihan A, Bruce I, Coakley D, Lawlor BA. The clock drawing test in primary care: Sensitivity in dementia detection and
specificity against normal and depressed elderly. Int J Geriatr Psychiatry 2001;16(10):935–40.

10. Storey J, Rowland JT, Basic D, Conforti DA, Dickson HG. The Rowland Universal Dementia Assessment Scale (RUDAS):
A multicultural cognitive assessment scale. Int Psychogeriatr 2004;16(1):13–31.

11. Alzheimer's Australia NT, University of Western Australia, National Ageing Research Institute. Validation of the Kimberley Indigenous
Cognitive Assessment Tool (KICA) in rural and remote Indigenous communities of the Northern Territory. Darwin: Alzheimer’s
Australia, 2009. Available at https://healthinfonet.ecu.edu.au/key-
resources/publications/1914/?title=Validation%20of%20the%20Kimberley%20Indigenous%20Cognitive%20Assessment%20Tool%20
%28KICA%29%20in%20rural%20and%20remote%20Indigenous%20communities%20of%20the%20Northern%20Territory [Accessed
12 August 2019].

12. Sepehry AA, Lee PE, Hsiung GY, Beattie BL, Jacova C. Effect of selective serotonin reuptake inhibitors in Alzheimer's disease with
comorbid depression: A meta-analysis of depression and cognitive outcomes. Drugs Aging 2012;29(10):793–806.

13. The Royal Australian and New Zealand College of Psychiatrists. Use of antidepressants to treat depression in dementia. Melbourne:
RANZCP, 2015. Available at www.ranzcp.org/news-policy/policy-submissions-reports/document-library/use-of-antidepressants-to-
treat-depression-in-deme [Accessed 12 August 2019].
10 RACGP aged care clinical guide (Silver Book) Part A. Dementia

14. Kitching D. Depression in dementia. Aust Prescr 2015;38:209–11. Available at www.nps.org.au/australian-

prescriber/articles/depression-in-dementia [Accessed 12 August 2019].

15. Bell JA, Le Couteur DG, McLachlan AJ, et al. Improving medicine selection for older people: Do we need an Australian classification
for inappropriate medicines use? Aust Fam Physician 2012;41(1–2):9–10. Available at
www.racgp.org.au/afp/2012/januaryfebruary/improving-medicine-selection-for-older-people [Accessed 12 August 2019].

16. Bridges-Webb C, Wolk J. Care of patients with dementia in general practice guidelines. Sydney: The Royal Australian College of
General Practitioners and NSW Health, 2003.

17. Clemson L, Mackenzie L, Roberts C, et al. Integrated solutions for sustainable fall prevention in primary care, the iSOLVE project:
A type 2 hybrid effectiveness-implementation design. Implement Sci 2017;12(1):12.
18. Family Caregiver Alliance. Toileting (for dementia). San Francisco: FCA, 2012. Available at www.caregiver.org/toileting-dementia
[Accessed 12 August 2019].

19. Alzheimer’s Society. How motor and sensory difficulties can affect eating. London: Alzheimer’s Society, 2018. Available at
www.alzheimers.org.uk/get-support/daily-living/eating-motor-and-sensory-difficulties [Accessed 12 August 2019].

20. Alzheimer’s Association. Daily care plan. Chicago, IL: Alzheimer’s Association, 2018. Available at www.alz.org/help-
support/caregiving/daily-care/daily-care-plan [Accessed 12 August 2019].

21. Sinclair C, Field S, Blake M. Supported decision-making in aged care: A policy development guideline for aged care providers in
Australia. 2nd edn. Sydney: Cognitive Decline Partnership Centre, 2018.

22. Kurrle S, Brodaty H, Hogarth R. Physical comorbidities of dementia. Cambridge: Cambridge University Press, 2012.

23. Livingston G, Sommerlad A, Orgeta V, et al. Dementia prevention, intervention, and care. Lancet 2017;390(10113):2673–734.

24. National Institute for Health and Care Excellence. Dementia: Assessment, management and support for people living with dementia
and their carers. London: NICE, 2018. Available at www.nice.org.uk/guidance/ng97 [Accessed 12 August 2019].

25. Van Doorn C, Gruber-Baldini AL, Zimmerman S, et al. Dementia as a risk factor for falls and fall injuries among nursing home
residents. J Am Geriatr Soc 2003;51:1213–18.

26. Ouslander JG, Simmons S, Schnelle J, Uman G, Fingold S. Effects of prompted voiding on fecal continence among nursing home
residents. J Am Geriatr Soc 1996;44:424–28.

27. Ostaszkiewicz J, Johnston L, Roe B. Timed voiding for the management of urinary incontinence in adults (Cochrane Review).
In: The Cochrane Library, Issue 1, 2004. Chichester: Wiley.

28. Birks J. Cholinesterase inhibitors for Alzheimer's disease. Cochrane Database Syst Rev 2006:25;(1):CD005593.

29. American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Beers criteria for
potentially inappropriate medication use in older adults. J Am Geriatr Soc 2015;63(11):2227–46.

30. McShane R, Westby MJ, Roberts E, et al. Memantine as a treatment for dementia. Cochrane Database Syst Rev 2019;3:CD003154.
 RACGP aged care clinical
guide (Silver Book)
5th edition
Part A. Behavioural and psychological
symptoms of dementia

General principles
• A structured work-up of behavioural and psychological symptoms of dementia (BPSD) is vital to its
management.

• Understanding the triggers for the patient’s behaviours can lead to optimal management.

• Non-pharmacological management is the first-line treatment option for BPSD.

• Pharmacological management of BPSD is only reserved for patients who do not respond to other
interventions.

• The risks of pharmacological treatment need careful consideration prior to prescription.

• Reassessment of patients with BPSD is important to down-titrate medications.

Practice points
Practice points References Grade
Conduct a comprehensive work-up of patients presenting with 2 Consensus-based
behavioural and psychological symptoms of dementia (BPSD), recommendation
including the family and carers

Document the patient’s triggers, describe the behaviours, frequency 4, 5 Consensus-based

and timing with the assistance of family members and carers by recommendation
using scoring tools

Review the patient’s medication to exclude drug-induced delirium 7 Consensus-based

as a cause for the BPSD recommendation
2 RACGP aged care clinical guide (Silver Book) Part A. Behavioural and psychological symptoms of dementia

Conduct an assessment to understand the social, cultural and 7 Consensus-based

religious norms of the patient recommendation

Consider changes to the patient’s environment, routine and tasks 9 Consensus-based

that may help to reduce distress in day-to-day activities recommendation

Seek advice from carers and residential aged care facility (RACF) 11 Consensus-based
staff on what they have tried and what has worked in the past recommendation

The first-line management of BPSD includes a person-centred, 13 Consensus-based

multidisciplinary management plan of non-pharmacological recommendation
approach

Prescription of antipsychotic medication can be effective, 11 Consensus-based

particularly for behaviours and distress that have been precipitated recommendation
by hallucinations and delusions, but must be carefully considered

Consider the use of antipsychotics (risperidone has the strongest 13 Grade of

evidence) in those with BPSD who cause ‘significant distress to Recommendation:
themselves or others’; treatment must be reviewed every one to Moderate
three months
Quality of Evidence:
Moderate

Conventional antipsychotic agents (eg haloperidol) are not 1 Consensus-based

recommended because of a lack of evidence of effectiveness and recommendation
side effects

Consider the risks and benefits of using medication to manage 12 Consensus-based

BPSD before prescribing recommendation

Introduction
Psychological and behavioural symptoms are an integral manifestation of dementia. Behavioural symptoms are
common in the intermediate stages of Alzheimer’s disease and at various stages in other types of dementia. 1

General practitioners (GPs) and residential aged care facility (RACF) staff can minimise and manage behavioural and
psychological symptoms of dementia (BPSD) effectively with a clear approach to the work-up, diagnosis and
management of the presentation.

Clinical context
There are three models of BPSD:

• Unmet need – this model directs thinking towards a cause of the symptoms. It describes the behavioural symptoms
as a manifestation of an unmet need. For example, is the patient in pain, hungry, thirsty or tired and not able to
express it?

• Lowered stress threshold – this model directs thinking towards a cause of the symptoms. It explains the behaviours
as a reaction to a stressor. Patients with dementia have less resilience and react to stressors that may seem subtle.

• Biological model – this model suggests that the behaviours are caused by a pathophysiological process (ie aberrant
neurotransmitters, other biological factors).
The benefit of considering these models is that it provides options when seeking a cause and deciding on
management.
 RACGP aged care clinical guide (Silver Book) Part A. Behavioural and psychological symptoms of dementia 3

In practice
Working up
Patients presenting with BPSD need a comprehensive work-up. Involving the patient’s family and carers are vital, as
these are the people who often see the patient exhibiting the behaviours. Clarifying the behaviours in detail aids in the
search for a cause, working out the differential diagnoses and gives guidance for management. 2

Document the triggers, and describe the behaviours, frequency and timing with the assistance of family members and
carers. The Neuropsychiatric Inventory Questionnaire 3 is useful for an objective measure of the patient’s behaviours.
Repeating the questionnaire allows for monitoring for any changes over time. 4,5
Addressing all of the individual symptoms of BPSD (Box 1) is outside of the scope of this guide; however, each of the
symptoms will be touched on when relevant.

Box 1. Broad classification of BPSD symptoms 6

• Aggression

• Agitation

• Anxiety

• Apathy

• Depression

• Disinhibited behaviours

• Nocturnal disruption

• Psychotic symptoms

• Vocally disruptive behaviours

• Wandering

A full clinical work-up is necessary, including a mental-state exam (as part of a mental assessment, and stands alone).
A full clinical work-up may include an assessment of:

• physical health

• psychological health

• cognition

• medication chart

• obs and bowel chart

• blood and urine investigations

• environmental and psychosocial stressors

• behaviour

• function

• unmet needs

• mobility and falls risk

• social needs

• carer needs

• capacity of discharge

• supports necessary to meet the patient’s needs.

4 RACGP aged care clinical guide (Silver Book) Part A. Behavioural and psychological symptoms of dementia

In some cases, the behaviours may be so severe that the GP may need to omit or modify parts of their work-up to
prevent increasing the symptoms (eg leaving out chest auscultation because it increases the agitation of the patient). In
this case, close observation of the respiratory rate and work of breathing could be the only signs elicited.
Part of the work-up should include a review of the patient’s medication to exclude drug-induced delirium as a cause for
the BPSD (refer to Part A. Medication management). 7
Expanding the assessment to understand the social, cultural and religious norms for the patient can reveal a cause for
agitation or similar symptoms. The approach used for the work-up of BPSD should be personalised, as someone with
differing expectations can interpret an interaction that may seem normal differently. Considering the BPSD behaviours
as a form of communication is helpful when assessing patients.

Management
The first-line management of BPSD includes a person-centred, multidisciplinary management plan of non-
pharmacological approach. The multidisciplinary team may include GPs, nurses, RACF staff, carers, families, other
specialist medical practitioners (eg geriatrician, psychogeriatrician), pharmacists and allied health professionals.
Changes to the patient’s environment, routine and tasks may help to reduce distress in day-to-day activities. Refer to
Dementia Australia for help sheets on daily care (eg hygiene, dressing, safety), behavioural issues (eg sundowning,
wandering, aggression, agitation), and changes that can be made to the patient’s environment. Dementia Support
Australia’s BPSD guide: Managing behavioural and psychological symptoms of dementia is a helpful resource and
goes into detail regarding management.
Assisting carers and family in the community and staff at the RACF is important as they can have variable experiences
with managing patients with BPSD. On the other hand, experienced staff are a valuable source of advice. Asking RACF
staff and carers what they have tried and what has worked in the past can help gain valuable insight into the
management of the patient. The Agitation decision-making framework is a guide for nursing staff and carers, and can
be a useful resource. 8
Behavioural interventions may include: 9

• tailored activities program – setting up activities that are tailored to the interests of the patient 10

• music therapy

• aromatherapy

• physical exercise

• bright light therapy

• touch therapy

• combined activities (ie a mix of the above).

Because of the serious nature of delirium, delirium should be ruled out if a patient with dementia becomes acutely
disturbed. A common cause of delirium is the medications that the patient is on, including those used to manage
BPSD.3

Pharmacological management
Medication for the management of distressing BPSD may be considered in addition to non-medication interventions.
Antipsychotic medication can be effective, particularly for behaviours and distress that have been precipitated by
hallucinations and delusions. 11 The risks and benefits of using medication to manage BPSD need to be carefully
considered. 12

For any treatment, the effect on quality of life is a key consideration, including potential benefits and risks. For example,
a GP may decide that the risk of the medication used is outweighed by the harm of a hospital admission, and in this
case, would feel comfortable prescribing an antipsychotic.
Antipsychotic medication may be effective for specific indications; for example, depression, anxiety (refer to Part A.
Mental health), psychotic symptoms (hallucinations and delusions), motor activity and aggression. Starting doses
should be low and increased slowly with careful monitoring for adverse effects, especially sedation, postural
hypotension and Parkinsonism.12 Prescribing antipsychotic medications ‘as needed’ (pro re nata [PRN]) is discouraged.
However, a practice point is to convert the regular antipsychotic to ‘as needed’ when weaning the medication. This
way, appropriately qualified nursing staff are able to ‘top up’ the dose during the weaning process.
 RACGP aged care clinical guide (Silver Book) Part A. Behavioural and psychological symptoms of dementia 5

Risperidone has been approved by the Pharmaceutical Benefits Scheme (PBS) for the management of BPSD, and has
been found to be effective in reducing psychotic features and aggression. The National Health and Medical Research
Council’s (NHMRC’s) Clinical practice guidelines and principles of care for people with dementia highlights that those
with BPSD who cause ‘significant distress to themselves or others’ may be offered antipsychotic medications such as
risperidone. 13 The use of risperidone should be reviewed every one to three months.
Although risperidone has fewer serious adverse effects than other antipsychotics and is better tolerated, it may
sometimes cause extrapyramidal side effects, drowsiness, hypotension, hyperglycaemia and increased risk of
cerebrovascular accidents.11,14 It is important to ask the RACF staff to monitor and report signs of possible adverse
effects, including abnormal movements of the face, trunk and limbs; dizziness or fainting on standing; sudden
weakness or numbness in the face, arms or legs; speech or vision problems; or worsening diabetic control.12
Conventional antipsychotic agents (eg haloperidol) are not recommended because of a lack of evidence of
effectiveness, common extrapyramidal side effects and sedative anticholinergic side effects.1 They should not be used
in patients with suspected Lewy body dementia or Parkinson’s disease.11

Selective serotonin reuptake inhibitors (SSRIs) are helpful in managing depressive symptoms and aggression in
residents with dementia. 15 There is some evidence that citalopram is effective in the management of agitation. 16
Benzodiazepines may exacerbate cognitive impairment in dementia and increase the risk of falls and associated injury;
however, these can be used for severe anxiety and agitation. Oxazepam is a common choice due to its short half-life
and uncomplicated metabolism. 17 Benzodiazepines can be used in an ‘as needed’ capacity for times when behaviours
escalate; however, GPs need to be aware of the associated adverse effects (especially falls in older people).

There is some evidence for the use of memantine for the medical management of agitation and aggression. Currently
there is no evidence for valproate in the use of BPSD.

References
1. Stroup TS, Gray N. Management of common adverse effects of antipsychotic medications. World Psychiatry 2018;17(3):341–56.
2. Rossi S. Australian medicines handbook. Adelaide: Australian Medicines Handbook Pty Ltd, 2019. Available at www.amh.net.au
[Accessed 12 August 2019].
3. Cummings EA. Neuropsychiatric inventory. Sydney: DementiaKT hub, 1994. Available at
http://dementiakt.com.au/doms/domains/behaviour/npi [Accessed 12 August 2019].
4. Kaufer DI, Cummings JL, Ketchel P, et al. Validation of the NPI-Q, a brief clinical form of the Neuropsychiatric Inventory.
J Neuropsychiatry Clin Neurosci 2000;12(2):233–39.
5. Sheehan B. Assessment scales in dementia. Ther Adv Neurol Disord 2012;5(6):349–58.
6. Burns K, Jayasinha R, Tsang R, Brodaty H. Behaviour management – A guide to good practice: Managing behavioural and
psychological symptoms of dementia. Sydney: University of New South Wales, 2012. Available at
www.dementiaresearch.org.au/images/dcrc/output-files/328-2012_dbmas_bpsd_guidelines_guide.pdf [Accessed 12 August 2019].
7. Hersch EC, Falzgraf S. Management of the behavioral and psychological symptoms of dementia. Clin Interv Aging 2007;2(4):611–21.
8. University of Western Sydney: Agitation decision-making framework for nurses and care staff caring for people with advanced dementia.
Sydney: UWS, 2009. Available at www.uws.edu.au/__data/assets/pdf_file/0007/76237/Agitation_Guidelines.pdf [Accessed 12 August
2019].
9. De Oliveria AM, Radanovic M, de Mello PCH, et al. Nonpharmacological interventions to reduce behavioral and psychological symptoms
of dementia: A systematic review. Biomed Res Int 2015;2015:218980.
10. Gitlin LN, Winter L, Earland TV, et al. The Tailored Activity Program to reduce behavioral symptoms in individuals with dementia:
Feasibility, acceptability, and replication potential. Gerontologist 2009;49(3):428–39.
11. Psychotropic Expert Working Group. Psychotropic. Adelaide: Therapeutic Guidelines, 2019.
12. Madhusoodanan S, Ting MB. Pharmacological management of behavioral symptoms associated with dementia. World J Psychiatry 2014
22;4(4):72–79.
13. Guideline Adaptation Committee. Clinical practice guidelines and principles of care for people with dementia. Sydney: Guideline
Adaptation Committee, 2016. Available at http://sydney.edu.au/medicine/cdpc/documents/resources/Dementia-Guideline-
Recommendations-WEB-version.pdf [Accessed 12 August 2019].
14. Macfarlane S, O’Connor D. Managing behavioural and psychological symptoms in dementia. Aust Prescr 2016;39:123–25. Available at
https://nps.org.au/australian-prescriber/articles/managing-behavioural-and-psychological-symptoms-in-dementia#f1 [Accessed
12 August 2019].
15. Scott E, Pesiah C, Hickie I, Ricci C, Davenport T. A depression management program for older patients and their general practitioners.
Melbourne: SPHERE: A national mental health project, 1995.
16. Porsteinsson AP, Keltz MA, Smith JS. Role of citalopram in the treatment of agitation in Alzheimer’s disease. Neurodegener Dis Manag
2014;4(5):345–49.
17. Dinis-Oliveira RJ. Metabolic profile of oxazepam and related benzodiazepines: Clinical and forensic aspects. Drug Metab Rev
2017;49(4):451–63.
 RACGP aged care clinical
guide (Silver Book)
5th edition
Part A. Short-term pharmacotherapy
management of severe BPSD

General principles

• The use of short-term pharmacotherapy management of severe BPSD to manage challenging behaviours
in dementia requires a considered person-centred approach.

• Non-pharmacological measures are first-line treatment options, and should be attempted prior to
prescribing.

• Antipsychotics have a limited role in the management of challenging behaviours.

• Understanding the risks of antipsychotics and ensuring the benefits to the patient outweigh those risks is
paramount.

• Having a structured approach to the work up and management of challenging behaviours is important.

• Communication with residential aged care facility staff and guardians of the patient is critical.

• Regular review after initiating antipsychotics is expected.

• Clearly document consent, discussion of risks and failure of non-pharmacological strategies and who
provided consent in the patient’s medical record.

• The patient should be reviewed and attempts at weaning the medication as soon as possible but definitely
prior to 12 weeks.
2 RACGP aged care clinical guide (Silver Book) Part A. Short-term pharmacotherapy management of severe BPSD

Introduction
The RACGP believes the widespread use of the term ‘chemical restraints’ does not adequately or appropriately
reflect the potential role of short-term pharmacotherapy management of severe BPSD. This section will use the more
appropriate term ‘short-term pharmacotherapy management of severe BPSD’, which better reflects why GPs may go
down this path.
The Royal Commission into Aged Care Quality and Safety’s (Royal Commission’s) Interim report: Neglect was
released in November 2019 and defines restrictive practices as ‘activities or interventions, either physical or
pharmacological, which have the effect of restricting a person’s free movement or ability to make decisions. They
may involve restricting people with wrist restraints, abdominal and pelvic straps, vests, bed rails or deep recliner
chairs, confining a person to their room or a section of a facility, or sedating them with particular medication.’ 1
This chapter of the Silver Book will focus on the use of medications, particularly antipsychotics, and provide guidance
on the use of medications in managing behavioural and psychological symptoms of dementia (BPSD).

The use of antipsychotic medications in residential aged care facilities (RACFs) for the use of BPSD requires
significant consideration, and the general consensus in the medical community is that their use should be reduced or
avoided. Significantly, it is believed that the use of antipsychotics affect a patient’s liberty and dignity. 2 The use of
pharmacotherapy for BPSD without appropriate consent may also impinge on a patient’s legal rights, and may
constitute a legal offence. 3
From a clinical perspective, there can be significant and serious adverse effects on individuals who are prescribed
medications that may be considered to be a pharmacotherapy for BPSD, especially to their physical and mental
wellbeing. Importantly, there are fundamental issues around the effectiveness and success of pharmacotherapy for
BPSD.
Since 1 July 2019, stricter requirements around the use of pharmacotherapy for BPSD in government-funded RACFs
under the Aged Care Act 1997 (Cth) came into effect.

Notwithstanding the above, general practitioners (GPs) are well placed to prescribe and manage the use of
antipsychotic medications in RACFs. GPs are able to coordinate the care of the patient; communicate with families,
representatives (especially a legally appointed person with medical power of attorney) and staff using case
conferencing; and prescribe the medication with consideration. GPs are also well placed to review the patient
regularly after prescription, and monitor for effect and side effects. Guidelines suggest many patients are able to
come off antipsychotics after three months, and GPs have the expertise, systems and opportunity to review and
wean medications.
While the focus of this chapter is on the use of pharmacotherapy for BPSD in RACFs, most of the principles can also
be appropriately applied to the care of patients with BPSD living in the community. The use of referrals to
psychogeriatricians and geriatricians (including telehealth for rural and remote communities) can also be useful for
advice on assessment and medication (eg home-based patient with Lewy body dementia paranoia wanting to drive).

Clinical context
It is important to recognise that the use of psychotropic medications may be for the management of a diagnosed
physical or mental health illness or condition. As such, the use of psychotropic medications in those instances cannot
be considered a pharmacotherapy for BPSD. The restriction of an individual’s mental state must be differentiated with
the management and treatment of a diagnosed illness or condition.

Psychotropic medications are most commonly prescribed to patients who exhibit BPSD (refer to Part A. Behavioural
and psychological symptoms of dementia). The work up of BPSD and non-pharmacological management of BPSD,
highlighted in that chapter, are vital and must precede the use of pharmacological treatments. This is an essential
part of optimum clinical care. Potential reversible causes of deterioration in behavior should always be given due
consideration. Other causes of distress should also be explored (eg noisy neighbours in the RACF, family issues,
anniversary effects).

The use of pharmacological treatments has been found to be effective for those with severe agitation and physical
aggression associated with the risk of harm, paranoia, delusions and hallucinations or comorbid pre-existing mental
health conditions. It is prudent to be familiar with behavioural symptoms that do not respond to antipsychotics (eg
undressing in public, wandering, calling out, restlessness, day–night reversal, inappropriate voiding or verbal
aggression).
 RACGP aged care clinical guide (Silver Book) Part A. Short-term pharmacotherapy management of severe BPSD 3

According to The Royal Australian and New Zealand College of Psychiatrists (RANZCP), antipsychotics should only
be used for those with dementia when there is severe agitation or aggression associated with a risk of harm,
delusions, hallucinations, or pre-existing mental illness.
Requests to prescribe antipsychotics can come from RACF staff, the representatives of the patient (especially a
legally appointed person with medical power of attorney) and the GP who recognises the need. Alternatively,
antipsychotics are commonly initiated in the hospital settings and the patient is discharged on the medications. In the
latter setting, it is paramount that the GP continues to review and assess the patient as described below.
GPs are the patient’s advocate, and it is important that pressure from staff and/or representatives (especially a legally
appointed person with medical power of attorney) do not overly influence the GP decision to prescribe the
medication. In saying that, communication with the staff and representatives is vital as the patient, by definition, will
have limited capacity to give consent. It is recommended that a case conference is arranged prior to initiating
antipsychotics and for the review.
It is important to note that RACF staff are now required to record consumers who received psychotropic medications
by completing a self-assessment tool. 4

In practice
The effective management of patients with challenging behaviours should include a personalised assessment and
care plan. 5
On admission to an RACF, a comprehensive medical assessment (CMA) is can be performed on all new patients and
it is recommended to do it within six weeks. It is an opportunity to include an assessment of the risk of challenging
behaviours and a management plan. The BPSD management plan will include information about restrictive practices,
especially if the patient has a history of, or potential for, serious harm or potential serious harm to the patient
themselves, other residents in the RACF and/or RACF staff. The management of BPSD symptoms requires a
multidisciplinary team approach and good communication between the care team and patient/their representatives
(especially a legally appointed person with medical power of attorney). A case conference may be a suitable
mechanism to facilitate those conversations. Predicting the need for management of challenging behaviours will allow
for a pre-emptive case conference and allow the RACF staff to prepare.

Non-pharmacological management
The first-line management should include a person-centred, multidisciplinary management plan of non-
pharmacological approaches. The multidisciplinary team may include GPs, nurses, RACF staff, carers, families, other
specialist medical practitioners (eg geriatrician, psychogeriatrician), pharmacists and allied health professionals.
Together, the multidisciplinary team should first seek to manage the underlying cause of the behaviour in order to
minimise or avoid the use of pharmacotherapy for BPSD. Importantly, this will include the early identification and
adoption of preventive and early intervention measures.

Non-pharmacological management plans must be person-centred, but may include: 6

• Environmental 7
– reduce environmental noise and lighting
– reduce risk of confusion
– improve lighting
– provide appropriate bedding

• Psychosocial 8
– engage and interact with familiar staff
– conduct sensory stimulating activities
– provide companionship
– provide sensory aids
– increased supervision
– appropriate staffing and training
4 RACGP aged care clinical guide (Silver Book) Part A. Short-term pharmacotherapy management of severe BPSD

• Pharmacological
– medication management (refer to Part A. Medication management)
– deprescribing (refer to Part A. Deprescribing)
– polypharmacy (refer to Part A. Polypharmacy)
– nutrition and hydration
– pain management (refer to Part A. Pain)
The prescription of Pharmaceutical Benefits Scheme (PBS) approved psychotropic drug (ie risperidone), can only be
prescribed after non-pharmacological management have been attempted and failed. 9

Pharmacological management
The use of pharmacological management should only be considered after attempts of non-pharmacological
management have failed, and co-administered with other non-pharmacological management. 10 While the use of
antipsychotics can assist with patients who pose a serious risk of harm to themselves, other residents or RACF staff,
it can still be a stressful process for all individuals involved.
Medical practitioners need to be cognisant that the use of antipsychotics must be:

• for the benefit of the patient.

• to prevent harm or potential serious harm to the patient, other residents and/or RACF staff

• a last resort in a setting requiring an urgent response

• the least restrictive option

• carefully monitored, reviewed and clinically observed

• previously documented in the patient’s management plan, if necessary

– clear and unambiguous instructions on when the pharmacotherapy for BPSD can be used
– identify the precipitating and exacerbating factors
– suggest graded series of responses

• documented in the patient’s notes

• discussed and reviewed with the patient

• subject to regular review (eg three monthly)

• accompanied by the appropriate consent

• appropriately communicated to the patient and their representatives (especially a legally appointed person with
medical power of attorney)

• accompanied by a careful assessment of the patient’s safety.

Adverse effects
The misuse of psychotropic medicines may significantly affect the individual patient, and can adversely
affect: 11,12,13,14,15

• sedation, gait disturbances and increased risk of falls and fractures

• urinary tract infections

• urinary and faecal incontinence

• cognitive impairment and confusion

• risk for extrapyramidal side effects (eg restlessness, agitation)

• risk of respiratory complications (eg pneumonia), stroke and heart rhythm abnormalities, cerebrovascular events
(eg stroke)
 RACGP aged care clinical guide (Silver Book) Part A. Short-term pharmacotherapy management of severe BPSD 5

• risk of death.
Available literature has also found that the long-term use of benzodiazepines can lead to long-term cognitive
impairment and increased risk of dementia. 16,17

Initiating antipsychotics
Once it has been established that antipsychotics are necessary for the comfort, dignity and safety of the patient and
non-pharmacological management has failed, it is appropriate to initiate them.

• Assess the patient for contraindications for the medication.

• Communicate with the patient’s legally appointed person with medical power of attorney regarding the decision
and obtain their consent.

• Communicate with the RACF staff regarding the need for, the use of and observable side effects of the prescribed
antipsychotic, and document the above.

• Prescribe the medication at a low dose.

• Review the patient within a week and regularly thereafter as required.

• Set a reminder and arrange to review the patient in 12 weeks with the plan to wean and cease the medication if
possible.

Consent
Failure to obtain a patient or their legally appointed person with medical power of attorney’s lawful consent before the
administration of pharmacotherapy for BPSD may infringe on the patient’s legal rights. It is therefore important to
clearly document the following in the patient’s medical record:

• consent

• discussion of risks and failure of non-pharmacological strategies

• who provided consent.

Decision making regarding care and treatment of those in RACFs must operate within state and territory legal
frameworks. State and territory legislation provides guidance on when a patient is unable to provide consent to
receiving medical treatment, and circumstances under which a substitute decision maker is able to assume
responsibility.
The various legislation allows patients who have capacity to make arrangements for a substitute decision maker if
and when they do not have the capacity to provide consent. 18 In New South Wales, if an individual is unable to
provide consent to a medical practitioner, they must seek consent from an authorised individual to provide consent. 19
It is therefore imperative for RACFs and medical practitioners to be aware of the legislation governing consent if it is
determined to be necessary to use a pharmacotherapy for BPSD on a patient. However, in the acute clinical setting,
this may be impractical and may lead to further potential harm to the patient, other residents in the RACF and RACF
staff.
In situations where the use of pharmacotherapy for BPSD may be necessary, the patient is most likely unable to
provide informed consent. Legislation and common law then indicates that informed consent must be obtained from a
substitute decision maker; however, in reality, this can often be difficult to actualise.

It must be highlighted that in acute situations, where there is an urgent need to act quickly to safeguard the patient or
others, restrictive practices may necessary and required. In this case, the judgement of the GP on starting the
medication is appropriate; however, obtaining consent as soon as practically possible is imperative. These issues
may be addressed by identifying the potential situation with the patient and family, and obtaining the necessary
consent to act before the acute situation occurs.

Reviewing and weaning

As highlighted by the NSW Ministry of Health, ‘[s]ince the natural history of BPSD is variable (symptoms may be
intermittent and may settle spontaneously), it is recommended that the use of such agents is time limited and
reviewed for their potential discontinuation at least three-monthly’. 20
6 RACGP aged care clinical guide (Silver Book) Part A. Short-term pharmacotherapy management of severe BPSD

Most practices have a process set up to set reminders for patients and GPs, and the GP can use this process to
remember to review the patient after 12 weeks or less. Alternatively, another strategy would be to prescribe for a
defined period of time on the medication chart.
Extrapolating from the adverse effect profile, Table 1 provides recommendations for assessment at the three-month
antipsychotic review.

Table 1. Consider the following at the three-month antipsychotic review

Assessment Related adverse effect or reason for assessment

Assessment of behaviour Agitation, anxiety as a side effect of antipsychotics

Movement disorders (eg rigidity, tremor, abnormal involuntary

movements, muscle stiffness), sedation, anticholinergic effects (eg dry
Adverse effects
mouth, constipation), falls, confusion

Documentation of previous attempts at

ceasing the antipsychotic

Outcome of previous attempt.

Non-pharmacological methods used that

Guidelines
have failed/worked

Bowel actions Constipation

Sleep assessment Somnolence, insomnia

Weight measurement Weight gain or loss

Pain assessment Extremity pain, headache

Cardiovascular system examination:

Bradycardia/QT prolongation
Consider electrocardiography (ECG)

Consider blood tests Agranulocytosis, lipids, blood glucose levels

Taking a history and documenting the following points is part of the assessment:

• When was the last attempt at weaning?

• Outcome of previous weaning attempt.

• Pain, bowel actions and sleep assessment.

 RACGP aged care clinical guide (Silver Book) Part A. Short-term pharmacotherapy management of severe BPSD 7

• Behaviour assessment using appropriate tools (eg Neuropsychiatric Inventory).

• Assess the patient’s alcohol use and smoking status, as these may affect the use of psychotropic medications.
On examination, document the following.

• weight.

• neurological exam – consider parkinsonism, gait disturbance, tremor.

• pulse rate and rhythm.

Consider the following Investigations:

• full blood count, total cholesterol, triglycerides, high-density lipoprotein, and blood glucose levels or glycated
haemoglobin (HbA1c) every three to six months, if indicated

• electrocardiography (ECG), if possible.

The actions following on from the assessment would be to:

• plan to wean and cease the medication

• continue with the medication – It will need to be clearly noted as to the reasons and indication for continuing

• consider that continuing the medication would follow the same advice above regarding initiating the medication

• conduct a case conference to discuss the plan for the following three months

• consider calling Dementia Behaviour Management Advisory Service (DBMAS) and Severe Behaviour Response
Team (SBRT) if these behaviours persists.

Conclusion
As with many decisions a GP makes, the use of antipsychotic medications, which can potentially be viewed as a
pharmacotherapy for BPSD, needs to be made with consideration and care. The focus is on the distress of the
patient and managing their comfort and dignity. Since managing BPSD requires a multidisciplinary team approach,
the RACF has a role and responsibility in the care of the patient. However, aiding and advising the RACF staff on
non-pharmacologic management can be part of the GPs role when advocating for the patient.
GP’s experience and expertise in coordinating care, seeing patients regularly and making difficult decisions for the
good of their patients, makes them well placed to manage this challenging condition.
It is common for patients with challenging behaviours to improve within three months and being part of the team that
has made a significant difference to them, is a meaningful and satisfying part of the GPs work life.

Resources
• Dementia Support Australia
– BPSD guide app
– A clinician’s field guide to good practice – Managing BPSD

• Department of Health and Human Services’s Managing behavioural and psychological symptoms of dementia

• Dementia Behaviour Management Advisory Service (DBMAS) and Severe Behaviour Response Team (SBRT)
8 RACGP aged care clinical guide (Silver Book) Part A. Short-term pharmacotherapy management of severe BPSD

References
1. Royal Commission into Aged Care Quality and Safety. Interim report: Neglect. Adelaide: Royal Commission into Aged Care Quality
and Safety, 2019. Available at https://agedcare.royalcommission.gov.au/publications/Pages/interim-report.aspx [Accessed 11
November 2019].

2. Australian Law Reform Commission. Elder abuse – A national legal response. Brisbane: ALRC, 2017. Available at
www.alrc.gov.au/publication/elder-abuse-a-national-legal-response-alrc-report-131 [Accessed 6 November 2019].

3. Office of the Public Advocate Queensland. Legal frameworks for the use of restrictive practices in residential aged care: An analysis of
Australian and international jurisdictions. Brisbane: OPAQ, 2017. Available at
https://www.justice.qld.gov.au/__data/assets/pdf_file/0005/524426/restrictive-practices-in-aged-care-final.pdf [Accessed 6 November
2019].

4. Aged Care Quality and Safety Commission. Self-assessment tool for recording consumers receiving psychotropic medications.
Canberra: ACQSC, 2019. Available at www.agedcarequality.gov.au/resources/self-assessment-tool-psychotropic-medications
[Accessed 14 November 2019].

5. Aged Care Quality and Safety Commission. Results and processes guide. Canberra: ACQSC, 2018. Available at
www.agedcarequality.gov.au/resources/results-and-processes-guide [Available at 6 November 2019].

6. Department of Health and Human Services. Managing behavioural and psychological symptoms of dementia. Melbourne: DHHS,
2019. Available at www2.health.vic.gov.au/hospitals-and-health-services/patient-care/older-people/cognition/dementia/dementia-bpsd
[Accessed 14 November 2019].

7. Day K, Carreon D, Stump C. The therapeutic design of environments for people with dementia: A review of the empirical research.
Gerontologist 2000;40(4):397–416.

8. Burns K, Jayasinha R, Tsang R, Brodaty H. Behaviour management: A guide to good practice managing behavioural and
psychological symptoms of dementia (BPSD). Sydney: Dementia Collaborative Research Centre – Assessment and Better Care,
2012. Available at https://dementia.com.au/downloads/dementia/Resources-Library/Understanding-Responding-
Behaviour/DBMAS_Guide_21_05_12-for_USB_pdf.pdf [Accessed 6 November 2019].

9. Pharmaceutical Benefits Scheme. Risperidone. Canberra: PBS, 2019. Available at www.pbs.gov.au/medicine/item/1842Y-1846E-

3169T-3170W-3171X-3172Y-8100H-8780D-8781E8782F-8787L-8789N-8869T-9079W-9293D [Accessed 6 November 2019].

10. Rajkumar AP, Ballard C, Fossey J, et al. Apathy and its response to antipsychotic review and nonpharmacological interventions in
people with dementia living in nursing homes: WHELD, a factorial cluster randomized controlled trial. J Am Med Dir Assoc
2016;17(8):741–47.

11. Dyer S, Harrison S, Laver K, Whitehead C, Crotty M. An overview of systematic reviews of pharmacological and non-pharmacological
interventions of the treatment of behavioural and psychological symptoms of dementia. Int Psychogeriatr 2018;30(3):295–309.

12. Schneider L, Dagerman L, Insel P. Efficacy and adverse effects of atypical antipsychotics for dementia: Meta-analysis of randomised,
placebo controlled trials. Am J Geriatr Psychiatry 2006;14(3):191–210.

13. Tang W, Chow Y, Koh S. The effectiveness of physical restraints in reducing falls among adults in acute care hospitals and nursing
homes: A systematic review. JBI Libr Syst Rev 2010;8(34 Suppl):1–26.

14. Ballard C, Hanney M, Theodoulou M, et al. The dementia antipsychotic withdrawal trial (DART-AD): Long-term follow up of a
randomised placebo-controlled trial. Lancet Neurol 2009;8(2):151–57.

15. Hien L, Cumming R, Cameron I, et al. Atypical antipsychotic mediations and risk of falls in residents of aged care facilities. J Am
Geriatr Soc 2005;53(8):1290–95.

16. Wu CS, Wang SC, Chang IS, Lin KM. The association between dementia and long-term use of benzodiazepine in the elderly: Nested
case-control study using claims data. Am J Geriatr Psychiatry 2009;17(7):614–20.

17. Billioti de Gage S, Begaud B, Bazin F, et al. Benzodiazepine use and risk of dementia: Prospective population based study. BMJ
2012;345:e6231.

18. Medical Treatment Planning and Decisions Act 2016 (Vic) ss 26, 50; Advance Care Directives Act 2013 (SA) s 23; Powers of Attorney
Act 1998 (Qld) s 35; Advance Personal Planning Act 2013 (NT) s 8; Medical Treatment (Health Directions) Act 2006 (ACT) s 7;
Guardianship Act 1987 (NSW) ss 6, 6G.

19. Guardianship Act 1987 (NSW).

20. NSW Ministry of Health. Assessment and management of people with behavioural and psychological symptoms of dementia: A
handbook for NSW clinicians. Sydney: NSW Ministry of Health, 2013.
 RACGP aged care clinical
guide (Silver Book)
5th edition
Part A. Osteoporosis

General principles

• Consider osteoporosis in older people, especially those living in residential aged care facilities.

• Osteoporosis is subclinical, but is a risk factor for fractures.

• Use a fracture risk calculator to assess patient risk.

• Treat osteoporosis with lifestyle changes and pharmacological treatment.

• Check for adequate dietary intake of calcium, and supplement if necessary.

• Vitamin D supplementation may be required if the patient has inadequate levels of exposure to the sun.

• A careful risk–benefit analysis is important prior to initiation of pharmacological treatment for osteoporosis.

Practice points
Practice points References Grade
Assess the fracture risk of all older people using risk calculators 1 Grade of
that have been validated Recommendation: D
Consider vertebral fracture and X-ray if the patient has a clinical 1 Consensus-based
kyphosis or historical height loss of ≥3 cm recommendation
Consider calcium and vitamin D as preventive strategies and prior 1 Grade of
to medical treatment Recommendation: C
Recommend exercise, healthy eating, ceasing smoking and low 1 Consensus-based
alcohol intake as part of a healthy life, and contribution to good recommendation
bone health
Oral bisphosphonates and denosumab are effective options for the 1 Various
management of osteoporosis
2 RACGP aged care clinical guide (Silver Book) Part A. Osteoporosis

Introduction
Osteoporosis is an often-overlooked diagnosis, and patients in residential aged care facilities (RACFs), who are often
at high risk for fragility fractures, would benefit from appropriate and individualized prevention, assessment and
management. The RACGP’s Osteoporosis prevention, diagnosis and management in postmenopausal women and
men over 50 years of age, second edition, was published in 2017 and contains comprehensive and detailed
recommendations. 1 The purpose of this chapter in the RACGP aged care clinical guide (Silver Book) is to add some
interpretation to those guidelines for the RACF setting.

Clinical context
Osteoporosis is defined as low bone mineral density (BMD) and abnormal bone architecture. These changes lead to
increased risk of fragility fracture, where hip fractures in older people have a high mortality rate. 2 As osteoporosis is
subclinical, it is the risk of fractures that is most relevant to patients.

Assessing risk for fractures

There are multiple fracture risk calculators that have been validated and are available for use (Grade of
Recommendation: D), such as the following:1

• FRAX score 3

• Garvan Fracture Risk Calculator

Risk stratification is valid without a BMD test; 4 however, the Pharmaceutical Benefits Scheme (PBS) criteria for anti-
resorptive drugs require a BMD T-score of <–2.5 or a proven minimal trauma (or fragility) fracture.

The US National Osteoporosis Foundation guidelines recommend the commencement of treatment when the 10-year
risk of hip fracture is estimated to be ≥3% on the FRAX score, or when the 10-year risk of major osteoporotic fracture
is 20% or higher. 5 It has been proposed that many Australian residents of RACFs will fall into this risk category.

In practice
Primary prevention
Assessing the fracture risk of all residents in RACFs is good practice, as many of those assessed will be found to
have a high risk of fractures. A decision will need to be made as to whom to treat and for whom primary prevention is
unnecessary. Balancing the decision with the concept of preventing polypharmacy is vital (refer to Part A.
Polypharmacy). Points to consider when making that decision include:

• prognosis – if the patient’s prognosis is poor, there is less benefit from prevention

• frailty – a higher frailty score indicates a poorer prognosis; however, a moderate frailty score may be a good
indicator for use of preventive medication (refer to Part A. Frailty)

• patient and family – patient and family goals and wishes are important to consider; this is an area where shared
decision making is critical

• whether the patient is able and willing to go for a dual-energy X-ray absorptiometry (DXA) scan or X-ray. These
investigations are not necessary for risk stratification, but are necessary for prescribing osteoporosis medication
on the PBS in the absence of a fragility fracture.

Secondary prevention
The above factors considered in primary prevention also hold true for secondary prevention. However, the indication
for treatment and the benefits accrued is higher for secondary prevention.
A practice point is to seek out the patient’s history regarding fractures. Often, there is a change of GP care when a
patient enters an RACF, and any previous history of more minor fractures in the patient’s history can be missed.
 RACGP aged care clinical guide (Silver Book) Part A. Osteoporosis 3

Consider that if the patient has a clinical kyphosis or historical height loss of ≥3 cm, there may be a vertebral fracture
and an X-ray may be prudent.1

Management
Lifestyle factors are an important part of osteoporosis management. Adequate calcium and vitamin D are not only a
preventive strategy in themselves, but also require consideration prior to medical treatment (Grade of
Recommendation: C).1 Hypocalcaemia during treatment can occur if the patient has a low dietary calcium intake or
low vitamin D stores.
Exercise, healthy eating, ceasing smoking and low alcohol intake are part of a healthy life, and contribute to good
bone health. In an RACF setting, exercise and diet are often in the realm of the staff. Adding recommended exercises
and diet to the patient’s care plan will encourage the RACF to implement your plan.1

Pharmacological management
Calcium and vitamin D may be considered for older people in RACFs where appropriate, as these have previously
been shown to have some evidence in the prevention and reduction in the risk of falls in RACFs (refer to Part A.
Falls). 6 Vitamin D in individuals with low levels reduces rate of falling. Consider calcium supplementation if dietary
calcium is considered to be inadequate.1
Oral bisphosphonates and denosumab are effective options for the management of osteoporosis (refer to reference 1
for variations in recommendation); however, consideration needs to be made regarding administration and side
effects. The recommendation is that bisphosphonates are given in a fasting state (eg prior to breakfast), and the
patient is to remain upright and seated for 30 minutes after taking the medication. 7,8,9 The logistics of this may be
challenging in an RACF.
Osteonecrosis of the jaw is a worrisome but rare complication of bisphosphonates. A careful review of the dental
hygiene of the patient is recommended prior to starting the drug.
Denosumab is given as a subcutaneous injection every six months. It is important to monitor for hypocalcaemia,
especially since patients in RACFs are at risk of decreased renal function (estimated glomerular filtration rate [eGFR]
<30 mL/min). Replacing calcium and vitamin D prior to the initiation of denosumab and monitoring serum calcium
after seven to 10 days is important in RACF patients to avoid hypocalcaemia.

References
1. The Royal Australian College of General Practitioners and Osteoporosis Australia. Osteoporosis prevention, diagnosis and
management in postmenopausal women and men over 50 years of age. 2nd edn. East Melbourne, Vic: RACGP, 2017.

2. Panula J, Pihlajamaki H, Mattila VM. Mortality and cause of death in hip fracture patients aged 65 or older – A population-based study.
BMC Musculoskelet Disord 2011;12:105.

3. Sandhu SK, Nguyen ND, Center JR, Pocock NA, Eisman JA, Nguyen TV. Prognosis of fracture: Evaluation of predictive accuracy of
the FRAX™ algorithm and Garvan nomogram. Osteoporos Int 2010;21(5):863–71.

4. Marques A, Lucas R, Simões E, Verstappen SMM, Jacobs JWG, da Silva JAP. Do we need bone mineral density to estimate
osteoporotic fracture risk? A 10-year prospective multicentre validation study. RMD Open 2017;3(2):e000509. Available at
http://rmdopen.bmj.com/content/3/2/e000509 [Accessed 13 August 2019].

5. Cosman F, de Beur SJ, LeBoff MS, et al. Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int
2014;25(10):2359–81. Available at https://link.springer.com/article/10.1007/s00198-014-2794-2 [Accessed 13 August 2019].

6. Cameron ID, Dyer SM, Panagoda CE, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane
Database Syst Rev 2018;9:CD005465.

7. Gupta A, March L. Treating osteoporosis. Aust Prescr 2016;39:40–46.

8. Duque G, Lord SR, Mak J, et al. Treatment of osteoporosis in Australian residential aged care facilities: Update on consensus
recommendations for fracture prevention. J Am Med Dir Assoc 2016;17:852–59.

9. Reid IR, Birstow SM, Bolland MJ. Calcium and cardiovascular disease. Endocrinol Metab (Seoul) 2017;32(3):339–49.
 RACGP aged care clinical
guide (Silver Book)
5th edition
Part A. Pain

General principles
• Pain needs to be considered in older people as they may not complain of any symptoms.

• Pain symptoms cannot to be ignored in older people in residential aged care facilities or those in the
community.

• A full assessment of pain is important prior to management.

• Consider non-pharmacological treatment options for pain management first.

• Assess the risks and benefits prior to prescribing medications for pain.

• Paracetamol is first-line pharmacological management.

• Nonsteroidal anti-inflammatory drugs (NSAIDs) should be used with caution.

• Start opiates at a low dose and up-titrate to symptoms.

Practice points
Practice points References Grade
Consider assessment of pain on admission to the residential aged 4 Consensus-based
care facility, after a change in medical or physical condition, and as recommendation
symptoms arise
Ask about present pain (rather than in the past) as this is a reliable 4 Consensus-based
method of assessment for patients whose communication skills are recommendation
compromised
Consider using the Abbey Pain Scale for patients with dementia 5 Consensus-based
who cannot verbalise their pain; it may also be useful for cognitively recommendation
intact patients who are unable to verbalise, are not willing or cannot
talk about their pain
2 RACGP aged care clinical guide (Silver Book) Part A. Pain

Consider using the Modified Resident’s Verbal Brief Pain Inventory 6 Consensus-based
for residents who are able to verbalise their pain recommendation
Establish treatment goals with the patient and/or representative, 7 Consensus-based
taking into account their culture, beliefs and preferences recommendation
Non-pharmacological and complementary therapies may be used 18 Consensus-based
as standalone therapies, or in conjunction with pharmacological recommendation
treatments
Choose pain medication based on pain severity by beginning with a 19 Consensus-based
mild analgesic (eg paracetamol) and build up stepwise to opioids recommendation
for unrelieved pain only after first-line, non-pharmacological
management fails
Paracetamol is the preferred analgesic for older people, and is 20 Consensus-based
effective for musculoskeletal pain and mild forms of neuropathic recommendation
pain
Nonsteroidal anti-inflammatory drugs (NSAIDs) and 21 Consensus-based
cyclooxygenase-2 (COX-2) inhibitors should only be used at the recommendation
lowest possible dose and for a short period (ie five to seven days),
as the risk of side effects is high in the older person
Codeine has a short half-life, and is suitable for incident pain or 22 Consensus-based
predictable mild-to-moderate, short-lasting pain recommendation
Opioids should not be withheld if pain is moderate to severe, and if 17 Consensus-based
the pain is unresponsive to other interventions recommendation
Morphine is suitable for the treatment of severe pain in older 18 Consensus-based
people, and is available in forms for most routes of administration recommendation
Transdermal fentanyl can be used for ongoing severe pain; 27 Consensus-based
however, it is potent and long-acting, and the risk for delirium and recommendation
respiratory depression is high

Introduction
Acute pain has a prevalence of approximately 5% across all age groups, whereas the prevalence of chronic pain
increases with age. Specifically, the prevalence of chronic pain in residential aged care facility (RACF) residents is
challenging to measure but estimated to be around 80%. 1,2 As the population ages, the number of people with
chronic pain is expected to increase. The consequences of chronic pain include increased confusion, sleep
disturbance, nutritional alterations, impaired mobility, depression, social isolation, worsening pain, slowed
rehabilitation and increased risk of falls. 3

Clinical context
Pain can be acute or chronic. The difference between the two is defined not only by the length of time the patient is
experiencing the pain, but also the nature of the pain. Acute pain can last for a long time if there is ongoing
inflammation. Similarly, chronic pain is pain that persists after the inflammation from tissue damage resolves. The
significant clinical issue is therefore the sensitisation of the central nervous system, not just the passage of time.

Acute pain may occur concurrently with chronic pain, and should be investigated and treated accordingly. For chronic
pain, identification of pain patterns can help to establish a treatment regimen. Baseline pain is experienced constantly
for longer than 12 hours per day. Flare-up (intermittent) pain is transient periods of increased pain, and incident pain
flares up during an activity (eg turning in bed).
Diagnosis of the cause of pain affects treatment and choice of analgesia. Nociceptive pain results from somatic and
visceral stimulation or injury, while neuropathic pain results from injury to the nervous system. A common type of pain
seen in older people is nociceptive pain, often resulting from pathologies related to ageing (eg arthritis, osteoporosis,
vascular disease). Table 1 shows the different types of nociceptive and neuropathic pain.
 RACGP aged care clinical guide (Silver Book) Part A. Pain 3

It is important to note that chronic pain is a condition in its own right and does not need to be secondary to a cause. It
is important to seek a cause; however, due to sensitisation, chronic pain can exist on its own.

Table 1. Types of pain and their causes 4

Characteristic Nociceptive Nociceptive deep Nociceptive

of pain superficial somatic visceral Neuropathic
Origin of Skin, subcutaneous Bone joints, muscles, Solid or hollow Damage to nociceptive pathways
stimulus tissue; mucosa- tendons, ligaments; organs, deep
mouth, nose, superficial lymph nodes; tumour masses,
sinuses, urethra, organs and capsules, deep lymph nodes
anus mesothelial membranes
Examples Pressure ulcers, Arthritis, liver capsule Deep abdominal orTumour-related: brachial,
stomatitis distension or chest masses, lumbosacral plexus or chest wall
inflammation intestinal, biliary invasion, spinal cord compression.
ureteric colic Non-tumour related: postherpetic
neuralgia, postthoracotomy
syndrome, phantom pain
Description Hot, burning, Dull, aching Dull, deep Dysesthesia (pins and needles,
stinging tingling, burning, lancinating,
shooting),
allodynia, phantom pain, pain in
numb area
Localisation to Very well defined Well defined Poorly defined Nerve or dermatome distribution
site of stimulus
Movement No effect Worsening pain – May improve pain Nerve traction provokes pain, eg
patient prefers to be still sciatic stretch test
Referral No Yes Yes Yes
Local Yes Yes Maybe Yes
tenderness
Autonomic No No Nausea, vomiting, Autonomic instability: warmth,
effects sweating, blood sweating, pallor, cold, cyanosis
pressure and heart (localised to nerve pathway)
rate changes

Reproduced with permission from Department of Health and Ageing. Guidelines for a palliative approach in residential aged care. Canberra:
DoHA, 2004.

Attitudes to pain
Older people may not express their pain because of cognitive impairment and their attitudes and beliefs surrounding
pain. They may have a perception that ‘pain is part of being old’, and that there is little that can be improved. Fear of
addiction needs to be addressed as this can be a barrier to patients reporting pain to their general practitioner (GP).
Asking about discomfort, soreness or aching can lead to admissions of pain.
Pain is often expressed through behavioural symptoms, even in patients whose verbal communication skills are
intact. Symptoms include:

• aggression, resistance, withdrawal, restlessness

• facial expression – grimacing, fear, sadness, disgust

• verbalisations – self-reports of pain, requests for analgesia, requests for help, sighing, groaning, moaning, crying,
unusual silence.
Physiological changes with pain include:

• raised heart rate, pulse, temperature, respiratory rate, blood pressure, sweating

• abnormal skin colour

• discharge from eyes, nose, vagina or rectum

4 RACGP aged care clinical guide (Silver Book) Part A. Pain

• lesions to oral or rectal mucosa, skin

• distension of the abdomen, and swelling of limbs or body joints

• abnormal results on testing urine (eg presence of blood, leucocytes, glucose)

• functional decrease in mobility, range of movement, activity, endurance, and increase in fatigue

• changes in posture – standing, sitting, reclining.

In practice
Assessment
Consider assessment of pain:

• on admission to the RACF

• opportunistically in the community

• after a change in medical or physical condition

• as symptoms arise.
Assessment includes input from the patient, family, RACF staff, carers, other specialist medical practitioners and/or
allied health professionals. Regular reassessment is required to determine changes and the effect of interventions.
Self-reported pain is the usual method of assessing location, duration and intensity; however, the subjective nature of
pain makes quantification difficult. Asking about pain in the present (rather than in the past) is a reliable method of
assessment for patients whose communication skills are compromised by illness or cognitive impairment.
Multidimensional pain assessment scales have been developed for use in older people. The Abbey Pain Scale is
suitable for patients with dementia who cannot verbalise their pain, and may also be useful for cognitively intact
patients who are not willing or cannot talk about their pain. 5 The Modified Resident’s Verbal Brief Pain Inventory is
suitable for residents who are able to verbalise their pain. The same scale/s selected for the individual resident
should be used for reassessment. 6
A number of pain assessment tools are appropriate for use in RACFs, and can be divided into self-report tools,
observational behavioural tools and sensory testing tools (refer to Box 1 for more information).
 RACGP aged care clinical guide (Silver Book) Part A. Pain 5

Box 1. Pain assessment tools

Self-reported tools
Despite potential attitudinal barriers to patients accurately reporting their pain, self-reporting is still the gold standard.
Self-reporting scales incorporate words, pictures or numbers. The most effective scales are simply worded and
easily understood, and include the Numeric Rating Scale (with pain rated from 0 to 10) and the Verbal Descriptor
Scale (rating pain as either ‘no pain, ‘slight pain’, ‘mild pain’, ‘moderate pain’, ‘severe pain’, ‘extreme pain’ or ‘the
most intense pain imaginable’). Multidimensional scales, such as the Brief Pain Inventory, 7 are more complex but
can monitor pain intensity and pain-related interference in the patient’s life.

Observational tools
Patients with cognitive impairment can often self-report pain in a reliable and valid manner, 8 although as dementia
worsens, proxy scales may have increasing usage. Generally, these tools detect the presence or absence of pain in
those with dementia when self-reporting is insufficient. The tools typically measure behaviours that may be
manifestations of pain, but cannot differentiate from similar behaviours that are unrelated to pain (eg exertion),
resulting in high false-positive rates of 25–30%. 9 There is no consensus on which tool is best, so any of those
developed for geriatric settings are suitable; for example:

• Abbey Pain Scale 10

• Pain Assessment in Advanced Dementia Scale [PAINAD] 11

• Doloplus-2 12

• Non-Communicative Patient’s Pain Assessment Instrument [NOPPAIN] 13

• Pain Assessment Checklist for Seniors with Limited Ability to Communicate [PACSLAC]. 14
These tools differ in the items that describe pain, ease of use and time to administer. Recently, some of these scales
have also been found to be sensitive measures of pain severity.9
Although there are several observational scales, key behaviours indicative of pain are common to all. The top three
behaviours are negative:

• facial expressions (eg frowning, sadness, grimacing)

• body language (eg guarding, rigidity, fidgeting, pacing, altered gait)

• vocalisations (eg crying, pain noises, verbal aggression, moaning, groaning).

These three elements are validated in all non-verbal behaviour pain assessment scales for dementia. Other
additional behavioural indicators reflect the nuances of the various scales and may include items such as
consolability, behavioural changes (eg aggression), physiological changes (eg quickened pulse), physical changes
(eg bruises, lacerations), sudden changes in daily routines (eg eating habits, sleeping patterns) and altered
breathing. Wandering has recently been shown to be an unreliable indicator of pain and is predictive of lessened
pain. 15

Sensory testing tools

Identification of neuropathic pain often requires the use of sensory testing tools; these tests are non-invasive
procedures that can evaluate peripheral nerve function. Comprehensive testing is lengthy. For the physician visiting
an RACF, simple brush and pinprick tests are more practical:

• Brush tests are appropriate in identifying allodynia, a condition associated with neuropathic pain where normally
non-painful stimuli are perceived as painful.

• Pinprick tests are suitable in diagnosing hyperalgesia that is associated with neuropathic pain.
Hyperalgesia relates to increased sensitivity to a painful stimulus. Common causes (eg diabetes, cancer, stroke) or
patients’ reports of tingling, numbness, shooting or burning pain are flags for neuropathic pain, in which case these
tests may be illuminative. However, the utility of such testing in patients with advanced dementia is unclear.

Adapted with permission from Savvas S, Gibson S. Pain management in residential aged care facilities. Aust Fam Physician
2015;44(4):198–203. Available at www.racgp.org.au/afp/2015/april/pain-management-in-residential-aged-care-facilities [Accessed
13 August 2019].
6 RACGP aged care clinical guide (Silver Book) Part A. Pain

Management
Establish treatment goals with the patient and/or representative, taking into account their culture, beliefs and
preferences. The aim may be to eradicate the pain and/or reduce it to tolerable levels so that mobility and
independence can be restored or maintained. For example, chronic nociceptive pain due to degenerative arthritis
requires a balance between pain relief and maintenance of function; however, older people in the terminal stage of a
disease may require complete pain relief, even though mental and physical function is compromised.

Effective pain management relies on care planning to manage baseline pain and future pain episodes. Regularly
reassess pain, and review management if pain scores are repeatedly high and flare-up strategies are used more than
twice in 24 hours or regularly (ie every day).

Non-pharmacological management
The first-line management of pain in older people should focus on the use of non-pharmacological management
plans. Non-pharmacological management of pain works best on a multidisciplinary, interdisciplinary management
plan for chronic pain, with a focus on ensuring patient-centred, self-management approaches.
Evidence to support the importance of interdisciplinary approaches is growing. Patient outcomes of 60 pain services
in Australia and New Zealand that applied interdisciplinary approaches are showing significant reductions in
medication use. Additionally, 75% of patients reported improved mental health or reduced interference in the quality
of life caused by their pain. 16
An multidisciplinary team is likely to include the GP, other specialist medical practitioner, clinical psychologist or
psychiatrist, physiotherapist or other allied health professionals (eg occupational therapists, pharmacist), and may
include a dietitian and social worker or counsellor. 17 Nurses are also an important part of the multidisciplinary team.
Non-pharmacological and complementary therapies (eg aromatherapy, 18 guided imagery [not usually suitable for
people who are cognitively impaired], acupuncture, music 19) may be used as standalone therapies, or in conjunction
with medication. 20 Emotional support for patients in pain can be therapeutic when offered by their GP, RACF staff
and relatives/carers. Diversional therapies may help, as well as offering nutrition and fluids, ensuring the resident is
warm and comfortable, and reducing lighting and surrounding noise.
Physiotherapists who are trained to evaluate nociceptive and neuropathic pain can assist choosing non-
pharmacological therapies to enhance medication. Physical therapies include transcutaneous electrical nerve
stimulation (TENS), walking programs, strengthening exercises and massage. Heat or cold packs need to be used
with care to avoid burns or hyperalgesia. Cognitive behavioural therapies (CBTs) are beneficial for older patients,
including residents who have mild dementia. Patients will often benefit from a clear explanation about the cause of
their pain, as well as behaviours and positive thoughts to enhance their own capacity to manage pain.
Refer to Table 2 for more information on non-pharmacological approaches.

Table 2. Pain management strategies: Non-pharmacological approaches20

Approach Considerations
Physical therapy
Exercise • Recommended pain management strategy

• Inconsistent evidence whether one type of exercise is better than another

• Patient preference is the primary consideration

• Focus on strengthening, flexibility, endurance, and balance

• Individual capacity limits options

Foot orthotics, patellar taping • Foot orthotics may change gait pattern/muscle activation and reduce joint
loading

Manual therapy • Requires significant levels of skill and care

Transcutaneous electrical nerve • Consider for persistent pain when patient can provide accurate feedback
stimulation (TENS)
 RACGP aged care clinical guide (Silver Book) Part A. Pain 7

Physical modalities (eg heat) • Beneficial for acute pain as effects are transient

• Monitor for safety if used for patients with dementia

Occupational therapies
Assistive devices • Some evidence of reducing functional decline and pain intensity
(eg walking frames)
• Can increase pain if used incorrectly

Psychological approaches
Cognitive behavioural therapy • Demonstrated benefit for patients in aged care
(CBT)
• Recommended if delivered by a professional

Complementary and alternative medicine

Acupuncture • Consider for older people as adjunctive therapy

• May improve function and pain relief

• Duration of long-term effects are uncertain

Massage, Tai Chi, yoga • Consider for older people as adjunctive therapy

• Massage may have some benefit for non-specific lower back pain

Nutritional supplements • Some evidence that chondroitin and glucosamine improve pain and function in
osteoarthritis

Pharmacological management
The choice of medication is based on pain severity and should only begin after non-pharmacological management
plans have failed. Begin with a mild analgesic (eg paracetamol), and build up stepwise to opioids for unrelieved
pain. 21 Consideration must be given to the risk of using a stepwise approach (eg use of opioids on falls risk).
Consideration must also be given to balancing the effect of opiate-based analgesia against common side effects
(eg confusion, sedation, constipation, anorexia).
Regular medication for baseline pain, that maintains a therapeutic blood level, is more beneficial than administering
analgesia when the patient asks for it or as staff consider it necessary. Treat flare-up and incident pain with additional
analgesia. Analgesia can be given 30 minutes before activities such as pressure area care, dressings, physiotherapy
and hygiene procedures.

Tailoring analgesic medications to effect is good practice. Once any of the medications below are initiated, a follow-
up appointment to monitor the effect or lack of effect is warranted.

Paracetamol
Paracetamol is the preferred analgesic for older people, 22 and is effective for musculoskeletal pain and mild forms of
neuropathic pain. Lower doses should be used in patients with hepatic or renal impairment. Paracetamol is relatively
safe at moderate doses but poses a pill burden on older patients. The tablets are generally large and at moderate
doses consist of six tablets per day. Monitoring for effect and possibly ceasing paracetamol is an option if the effect
is minimal.

Nonsteroidal anti-inflammatory drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) inhibitors should only be used at the
lowest possible dose for a short period (ie five to seven days), as the risk of side effects is high in the older person. 23
Common side effects to monitor include gastrointestinal bleeding, cardiovascular side effects and NSAID-induced
nephrotoxicity.23
8 RACGP aged care clinical guide (Silver Book) Part A. Pain

Opioids
Codeine has a short half-life, and is suitable for incident pain or predictable mild-to-moderate, short-lasting pain.
About 10% of people lack the enzyme that converts codeine to the active opioid form; therefore, they will have no
analgesic benefit. There is also a high incidence of constipation associated with the use of codeine; monitoring bowel
actions and co-prescribing aperients is advisable. 24
Tramadol is a centrally acting analgesic that also weakly acts on opioid receptor, and as an inhibitor to noradrenaline
and serotonin reuptake. It is a useful medication in a significant minority of older people with chronic non-cancer pain,
but should be used with caution because of the high incidence of side effects (up to one-third experience nausea,
vomiting, sweating, dizziness or hallucinations) and medication interactions (eg with selective serotonin reuptake
inhibitors [SSRIs]). Tramadol should not be used with other drugs that can affect serotonin. Low doses are
recommended initially (ie 25–50 mg per day for the first three days), with careful titration and monitoring. Patients
aged ≥75 years should not have more than 300 mg per day. 25
Opioids should not be withheld for fear of inappropriate use if pain is moderate to severe, and if the pain is
unresponsive to other interventions. In general, commence with low doses of short-acting opioids, and titrate the
dosage slowly. More rapid dosage escalation is appropriate in very severe pain, cancer pain and palliative care. In
these situations, increase titration by 25% of the prescribed dose until pain ratings are 50% less, or the patient
reports satisfactory relief.25
To change the type of opioid medication or route of administration, it is prudent to use an online opioid conversion
calculator (eg eviQ).
When changing the route of administration of opioids, adjust the new dose accordingly. Tolerance to opioids may
develop, which will necessitate an increase in dose or decreased interval of administration to achieve the same pain
relief. Long-acting opioid agents can be used in conjunction with short-acting opioids to treat incident pain. In
moderate-to-severe, non-cancer pain, dosage increments are usually less frequent; the target degree of pain relief
may need to be modified, maintaining function and other patient-defined goals. Apart from codeine, the main opioids
are morphine, oxycodone and fentanyl. 26
Morphine is suitable for the treatment of severe pain in older people, and is available in forms for most routes of
administration. Starting doses for severe, acute pain are:

• 10–30 mg, 3–4 hourly orally

• 2.5–5.0 mg, 4–6 hourly intramuscularly

• 2.5–10.0 mg, 2–6 hourly intravenously

• 2.5–10.0 mg, 2–6 hourly subcutaneously.

In chronic severe pain that is unresponsive to other interventions, after 24-hour dosage needs are established, long-
acting morphine can be introduced.26
Oxycodone is available in immediate-release and sustained-release form for oral administration. Immediate-release
oxycodone may be used for the initial establishment of tolerance and dosage needs, and later for flare-up pain.
Oxycontin (sustained release) is recommended for chronic pain with the recommended dose of 5–20 mg twice per
day. 27
The combination drug oxycodone/naloxene provides equivalent analgesia to oxycodone. The benefit of the
combination is that the incidence of constipation was 7% less than in the oxycodone alone; however, the long-term
effect on constipation is uncertain. Oxycodone/naloxene should not be used in those with moderate or severe hepatic
impairment. 28
Transdermal buprenorphine is an alternate option for chronic pain. The advantage is the formulation as a patch rather
than as an oral medication, where the absorption is as a slow release, which is beneficial. It is safe in renal failure
and recommended in older people. The initial dose is 10 mg per day and can increase up to 40 mg per day. 29
Transdermal fentanyl is used for ongoing severe pain; however, it is potent and long acting, and the risk for delirium
and respiratory depression is high. It should be used only when the patient has had opioids previously, and high
dosage needs are established. Fentanyl is metabolised in the liver and is suitable for patients with renal failure. Its
adverse effects are similar to those of morphine, but with a lower incidence of constipation and confusion. 30
Adjuvant medications used in pain management are medications not primarily used for pain treatment but that have
analgesic properties, for indications that include cancer pain management 31 and acute pain 32 where traditional,
conventional medications have failed. They may be given alone or in conjunction with analgesics, and include:

• low-dose tricyclic antidepressants – these are suitable for use in the relief of neuropathic pain (eg painful diabetic
neuropathy, postherpetic neuralgia, central post-stroke pain) or fibromyalgia syndromes. Start with 10 mg nocte,
 RACGP aged care clinical guide (Silver Book) Part A. Pain 9

and titrate over three to seven days to between 30 mg and 50 mg. Amitriptyline is the best-researched agent, and
nortriptyline may be better tolerated. Side effects include anticholinergic properties, postural hypotension,
sedation, constipation, urinary retention, and exacerbation of cardiac conditions,27 which are all prevalent in the
older population.

• anticonvulsants (eg carbamazepine) – these are suitable for trigeminal neuralgia, but require careful titration over
one month to reduce adverse effects27

• pregabalin – this is effective for neuropathic pain that does not respond to tricyclic medication. The dose should
be reduced in patients with renal failure. Side effects include dizziness and drowsiness. Stopping the medication
suddenly can lead to anxiety, insomnia, headache, nausea and diarrhoea 33, 34

• corticosteroids – these are suitable for inflammatory conditions (eg rheumatoid arthritis).

References
1. Takai Y, Yamamoto-Mitani N, Okamoto Y, Koyama K, Honda A. Literature review of pain prevalence among older residents of nursing
homes. Pain Manag Nurs 2010;11(4):209–23.

2. Zwakhalen S. Pain in elderly people with severe dementia: A systematic review of behavioural pain assessment tools. BMC Geriatr
2006;6:3.

3. Ruth D, Wong R, Haesler E. General practice in residential aged care: Clinical information sheet: Urinary tract infections. In:
Residential Aged Care Kit. Melbourne, Vic: North West Melbourne Division of General Practice, 2004.

4. Department of Health and Ageing. Guidelines for a palliative approach in residential aged care. Canberra: DoHA, 2004.

5. Lichtner V, Dowding D, Esterhuizen P, et al. Pain assessment for people with dementia: A systematic review of systematic reviews of
pain assessment tools. BMC Geriatr 2014;14:138.

6. Auret KA, Toye C, Goucke R, Kristjanson LJ, Bruce D, Schug S. Development and testing of a modified version of the brief pain
inventory for use in residential aged care facilities. J Am Geriatr Soc 2008;56(2):301–06.

7. Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med Singapore 1994;23:129–38.

8. Ferrell BA, Ferrell BR, Rivera L. Pain in cognitively impaired nursing home patients. J Pain Symptom Manage 1995;10:591–98.

9. Lukas A, Barber JB, Johnson P, Gibson SJ. Observer-rated pain assessment instruments improve both the detection of pain and the
evaluation of pain intensity in people with dementia. Eur J Pain 2013;17:1558–68.

10. Abbey J, Piller N, De Bellis A, et al. The Abbey pain scale: A 1-minute numerical indicator for people with end-stage dementia. Int J
Palliat Nurs 2004;10:6–13.

11. Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD)
scale. J Am Med Dir Assoc 2003;4:9–15.

12. Lefebvre-Chapiro S. The DOLOPLUS 2 scale – Evaluating pain in the elderly. Eur J Palliat Care 2001;8:191–94.

13. Snow AL, Weber JB, O’Malley KJ, et al. NOPPAIN: A nursing assistant-administered pain assessment instrument for use in dementia.
Dement Geriatr Cogn Disord 2004;17:240–46.

14. Fuchs-Lacelle S, Hadjistavropoulos T. Development and preliminary validation of the pain assessment checklist for seniors with limited
ability to communicate (PACSLAC). Pain Manag Nurs 2004;5:37–49.

15. Tosato M, Lukas A, van der Roest HG, et al. Association of pain with behavioral and psychiatric symptoms among nursing home
residents with cognitive impairment: Results from the SHELTER study. Pain 2012;153:305–10.

16. Blanchard M, Tardif H, Fenwick N, Blissett C, Eagar K. Electronic persistent pain outcomes collaboration annual data report 2016.
Wollongong, NSW: Australian Health Services Research Institute, University of Wollongong, 2017.

17. Cousins MJ, Gallagher RM. Fast facts: Chronic and cancer pain. Abingdon, UK: Health Press, 2011.

18. Lakhan SE, Sheafer H, Tepper D. The effectiveness of aromatherapy in reducing pain: A systematic review and meta-analysis. Pain
Res Treat 2016;8158693.

19. Garza-Villarreal EA, Pando V, Vuust P, Parsons C. Music-induced analgesia in chronic pain conditions: A systematic review and meta-
analysis. Pain Physician 2017;20(7):597–610.

20. Keilman L. Compendium of evidence-based nonpharmacologic interventions for pain in older adults. East Lansing, MI: Michigan State
University, 2015.

21. Savvas S, Gibson S. Pain management in residential aged care facilities. Aust Fam Physician 2015;44(4):198–203. Available at
www.racgp.org.au/afp/2015/april/pain-management-in-residential-aged-care-facilities [Accessed 13 August 2019].

22. American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons. Pharmacological
management of persistent pain in older persons. J Am Geriatr Soc 2009; 57(8):1331–46.

23.. Wongrakpanich S, Wongrakpanich A, Melhado K, Rangaswami J. A comprehensive review of non-steroidal anti-inflammatory drug
use in the elderly. Aging Dis 2018;9(1):143–50.
10 RACGP aged care clinical guide (Silver Book) Part A. Pain

24. Iedema J. Cautions with codeine. Aust Prescriber 2011:34:133–35. Available at www.nps.org.au/australian-
prescriber/articles/cautions-with-codeine [Accessed 13 August 2019].

25. Cavalieri TA. Managing pain in geriatric patients. J Am Osteopath Assoc 2007;107:ES10–16.

26. Ginsburg M, Silver S, Berman H. Prescribing opioids to older adults: A guide to choosing and switching among them. Geriatr Aging
2009;12(1):48–52. Available at www.medscape.com/viewarticle/705282_1 [Accessed 13 August 2019].

27. Galicia-Castillo MC, Weiner DK. Treatment of persistent pain in older adults. Waltham, MA: UpToDate, 2018. Available at
www.uptodate.com/contents/treatment-of-persistent-pain-in-older-adults [Accessed 13 August 2019].

28. NPS MedicineWise. Oxycodone-with-naloxone controlled-release tablets (Targin) for chronic severe pain. Canberra: NPS
MedicineWise, 2011. Available at www.nps.org.au/radar/articles/oxycodone-with-naloxone-controlled-release-tablets-targin-for-
chronic-severe-pain [Accessed 13 August 2019].

29. Vadivelu N, Hines RL. Management of chronic pain in the elderly: Focus on transdermal buprenorphine. Clin Interv Aging
2008;3(3):421–30.

30. NPS MedicineWise. Fentanyl patches (Durogesic) for chronic pain. Canberra: NPS MedicineWise, 2006. Available at
www.nps.org.au/radar/articles/fentanyl-patches-durogesic-for-chronic-pain [Accessed 13 August 2019].

31. Lussier D, Huskey AG, Portenoy RK. Adjuvant analgesics in cancer pain management. Oncologist 2004;9(5):571–91. Available at
https://theoncologist.alphamedpress.org/content/9/5/571.full [Accessed 13 August 2019].

32. Liu F, Ng KF. Adjuvant analgesics in acute pain. Expert Opin Pharmacother 2011;12(3):363–85.

33. NPS MedicineWise. Pregabalin (Lyrica) for neuropathic pain. Canberra: NPS MedicineWise, 2013. Available at
www.nps.org.au/radar/articles/pregabalin-lyrica-for-neuropathic-pain [Accessed 13 August 2019].

34. Australian Pain Management Association. Pregabalin. Woolloongabba, Qld: APMA, 2018. Available at
www.painmanagement.org.au/2014-09-11-13-35-53/2014-09-11-13-36-47/175-pregabalin.html [Accessed 13 August 2019].
 RACGP aged care clinical
guide (Silver Book)
5th edition
Part A. Dermatology

General principles
• Ensure and maintain skin integrity wherever possible.

• Avoid contact with skin irritants and prolonged localised pressure.

• Encourage a good diet, including zinc, vitamins C and D and adequate protein, for support of skin barrier
function and connective tissue health and cell repair.

• Maintain skin moisturisation with emollients.

• Systemic disease and medication reactions can first present with skin signs.

• Actinic (solar) damage is cumulative, so sun protection and skin cancer surveillance is important at all ages.

Practice points
Practice points References Grade
Use tools that may be beneficial in determining the effect of 4 Consensus-based
dermatological issues on the quality of life recommendation
Grade the severity of specific illnesses to determine the intensity of 5 Consensus-based
treatments needed and the progress to recovery recommendation
Reconsider the use of anticoagulants, nonsteroidal anti- 6 Consensus-based
inflammatory drugs (NSAIDs) and aspirin, as these worsen the recommendation
bruising in older people
Obtain a good history of past occupation and recreation that may 2 Consensus-based
point to long-term or ongoing exposure to environmental factors recommendation
Consider that itch can be caused by medication or a sign of a 8 Consensus-based
systemic condition recommendation
2 RACGP aged care clinical guide (Silver Book) Part A. Dermatology

Use of moisturisers and symptom relief with cold compresses 8 Consensus-based

supplemented by antihistamines and treating underlying conditions recommendation
are the mainstay of treatment of pruritus
Thorough skin examination is the mainstay of the early prevention 9 Consensus-based
and detection of skin cancers, depending on the individual’s sun recommendation
exposure history and previous skin cancers
Repair tears using the patient’s own skin flap as a ‘graft’ where 11–14 Consensus-based
possible recommendation
Always consider the need for biopsy of the wound edge and wound 12, 15 Consensus-based
swab for microbiology if the wound or ulcer is clinically infected recommendation
using the Levine technique
Use of barrier creams and ointments associated with reduction in 15 Consensus-based
causative factors are effective in the prevention of wounds and recommendation
ulcers
Use of pressure stockings and elevation of limbs can be effective in 17 Varying levels of evidence
control, prevention and assist in healing varicose ulcers for different patient group
Use of emollients (moisturisers) are paramount and need to be 13 Consensus-based
applied frequently if allergen penetrates the dermis recommendation
Always consider scabies when diagnosing and managing itch in 8 Consensus-based
older people, especially in residential aged care facilities recommendation

Introduction
The skin is the largest organ of the body. Its function is critical as a barrier to trauma, external irritants and infection,
and also as an indicator of internal illness through symptoms and signs related to the skin. 1

The skin has multiple functioning components, and the effects of ageing can affect the skin’s functioning and
structural resilience. Changes through exposure to environmental damage and the effects of time and genetic
makeup occur as an individual ages. The dermis and epidermis thin, elasticity and oils (sebum) are reduced, and
sensation falls due to reduction in nerve endings.

Clinical context
Currently, it is commonplace for older Australians to show actinic damage effects in their skin and have an increased
risk of developing skin cancers. It is hoped that as Australians reduce sun exposure via the public health measures
currently in place, solar damage effects to their skin will become less prevalent in later generations of older people.
Melanocytes also tend to congregate in the basement layer of the epidermis as individuals age and pigment is
produced in an uneven way. Seborrhoeic keratoses and lentigines, the so-called ‘age’, ‘wisdom’ or ‘liver’ spots, occur
as people age.
Elasticity also falls with increased wrinkles and more ‘sag’ of the skin, with reduced skin return during traction. The
skin appears more leathery and ‘weather worn’; this is known as elastosis due to damage of collagen and elastin
fibres. It is more common in sun-prone areas of the skin.1
It is important to note that aged skin has a reduced ability to sweat and less surface area of blood vessels. This
causes a problem with heat exchange, and older patients are more prone to heat intolerance (heatstroke) as a result.
Conversely, older people are also more susceptible to the cold with the thinning of subcutaneous fat. This highlights
the importance of environmental awareness and controls for older people.
Women’s skin tends to start drying, with reduction in sebum and oils in thinning epidermis, from the time of
menopause; for men, this is delayed, but is a significant problem for those aged >70 years. 2
As individuals age, an increasing number of benign and annoying lesions such as seborrhoeic keratoses, cherry
angiomata, skin tags and hyperkeratoses (ie rough thick skin spots) are all more commonly found. The skin of older
people tends to repair itself more slowly than those in younger age groups, and is dependent on nutritional status,
 RACGP aged care clinical guide (Silver Book) Part A. Dermatology 3

existing skin damage and vascular supply, which may be impaired. Underlying medical conditions (eg diabetes) can
also contribute to this slower repair.

Racial groups
Skin damage with ageing occurs in all racial groups. Skin signs of ageing occur because of the passing of time
(chronological ageing) and sun damage (actinic damage). Signs of ageing will occur even in the absence of sun
exposure, and the contribution of sun damage is less obvious in racial groups with darker skin. Patients of darker
complexion may manifest obvious ageing through loss of elasticity or areas of pigment variability that can be more
subtle to discern. Fairer skin types (Fitzpatrick skin type 1) display more classical actinic damage and skin ageing.
The Fitzpatrick skin type of an individual is useful to consider when assessing the skin of older people (refer to
Appendix 1).

Quality of life
Skin symptoms and manifestations may have a significant effect on an individual’s sense of self-worth, self-esteem
and social acceptance and behaviour. As with younger individuals, skin changes may cause significant depression,
anxiety and social withdrawal, and should be acknowledged and treated not only at a skin and appearance level but
also from a mental health perspective for best results. An ‘effect on life’ tool such as the Dermatology Quality of Life
Index (DLQI) may be beneficial, especially in the community settling. 3 Grading severity of specific illnesses
appropriately (eg PASI scores in psoriasis) helps to determine the intensity of treatments needed and the progress
to recovery. 4

Bruising
A common complaint among older people is how easily they bruise, often without recognised trauma. This is due to a
loss of connective tissue and increasing blood vessel fragility, leading to less resistance to shearing forces and less
resilience of the skin to knocks and scrapes. The result is a relatively more superficial and obvious bruise in the skin
of older people. This is often worsened by the use of anticoagulants, nonsteroidal anti-inflammatory drugs (NSAIDs)
and aspirin. 5

Environmental factors
Environmental factors play an important role in the skin of older people, including the following: 6

• Cumulative actinic exposure – especially ultraviolet (UV) exposure

• Smoking

• Exposure to irritant chemicals – for example, detergents, soaps and solvents

• Exposure to toxic chemical – for example, hydrocarbons, pesticides, arsenicals

• Contact with products that cause allergy – for example, fragrances, nickel, glues, some plants

• Low humidity – especially in heated residential facilities, contributing to skin dryness

It is therefore vital to obtain a good history of past occupation and recreation that may point to long-term or ongoing
exposure to the factors listed above. Further limiting the exposure and treating with barriers is appropriate.6

Itch
Most older people will have some symptoms referable to their skin, most commonly dry skin and itch. Itch is an
extremely common symptom in the older age group. Often, there is a simple explanation to the itch (eg dry skin,
co-existent dermatitis). Always consider scabies when diagnosing and managing itch in older people, especially in
residential aged care facilities (RACFs). 7 Itch can be caused by medication or be a sign of a systemic condition such
as iron deficiency or underlying cancer. Causes of itch should be investigated. 8
Senile pruritus is itch without rash or explanation in older people.

Moisturisers and symptom relief with cold compresses supplemented by non-sedating antihistamines, and treating
underlying conditions, are the mainstay of treatment.8,9
4 RACGP aged care clinical guide (Silver Book) Part A. Dermatology

In practice
Skin cancer
Skin cancers are the most common cancers in Australia, and general practice is the most common place for the
diagnosis and management of these tumours. Skin cancers increase in frequency as individuals age.
Thorough skin examination is the mainstay of early prevention and detection of skin cancers, at intervals dependent
on the individual’s sun-exposure history and previous skin cancers. This reduces morbidity and complications
associated with treatment. Dermatoscopy, if available, is helpful in diagnosing pigmented and vascular aberration.
Skin cancer management must be individualised to the patient, and the patient must appropriately consent if
diagnostic or therapeutic procedures are to be undertaken. In all age groups, surgical treatment is the mainstay for
cure; however, standard guidelines for treatment may not be appropriate for older patients. Treatment does need to
be tailored to the patient’s age, general health and wishes (non-curative treatment may be considered).

Keratinocyte
Keratinocyte cancers (ie squamous and basal cell carcinomas) are the most common indicators of significant sun
damage and possible precursor (solar keratosis). 10 Treatment for these premalignant and malignant conditions is
common in general practice, and the Cancer Council’s National Health and Medical Research Council (NHMRC)-
approved Basal cell carcinoma, squamous cell carcinoma (and related lesions) – A guide to clinical management in
Australia is a good reference.

Melanoma
Melanoma is recognised with increasing age, 11 and the current treatment protocols are available through the Cancer
Council’s Clinical practice guidelines for the diagnosis and management of melanoma. Older individuals are
especially at risk of in situ and thin melanoma in sun-damaged fields.
Melanoma treatment has progressed markedly in the past 10 years, and many patients are using biological
therapeutics to produce lasting longevity in previously rapidly fatal illness states. However, these biologic agents do
cause significant skin drying and hyperkeratosis, so good emollient use must be encouraged.

Wounds and ulcers

The skin of older people is less resilient and more prone to damage as they age. Shearing force in non-elastic skin
results in tears and abrasions occurring much more commonly. Skin tears are commonplace in older people given
that other intercurrent illnesses may affect balance and proprioception (eg Parkinson’s disease, diabetes,
cerebrovascular accident), leading to increased accidental trauma.
Repair of tears should use the patient’s own skin flap as a ‘graft’, where practicable. After cleaning the area, where
possible, the patient’s skin flap should be laid back in place and needs to be held in contact with the wound bed with
a firm dressing for several days. Deeper wounds must be assessed on their merits, and treatment is dependent on
depth, cause, location on wound, venous and arterial competence, infection risk and general nutritional
status. 12,13, 14,15

Decubitus or pressure ulcers need alertness for prevention in residents living in RACFs. Good nutritional status
should be the aim, and good nursing care is paramount by:

• frequent repositioning of the patient

• pressure alleviation techniques (eg air cushions, beds)

• appropriate dressings with elimination of infection.

Always consider the need for biopsy of the wound edge and wound swab for microbiology if the wound or ulcer is
clinically infected, using the Levine technique (refer to Appendix 2).14,16 Cutaneous cancer may present as non-
healing ulcers and should be considered in these circumstances.
Barrier creams and ointments associated with reduction in causative factors are effective in the prevention of wounds
and ulcers.
 RACGP aged care clinical guide (Silver Book) Part A. Dermatology 5

Varicose or stasis changes and eczema associated with varicose veins may lead to ulceration through various
mechanisms, including increased tissue pressure, fluid build-up and itch-scratch reactions with resulting trauma.
The use of pressure stockings and elevation of limbs can be effective in control, prevention and assisting in healing,
with varying levels of evidence for different patient groups. 17

Loss of skin barrier function

Dry skin is common in older people. Skin dehydration and impaired barriers cause the symptom of itch, and can bring
out dermatitis and eczemas in those who are susceptible to these conditions.
Increased allergen penetration to the dermis results in flares of contact allergies (eg nickel), but also exacerbates
previous atopic or seborrhoeic eczema. These flares can require intensive treatment, and emollients are paramount
and need to be applied frequently (up to every three hours in severe cases). Steroid creams and ointments need to
be considered.14
Dry skin can trigger the ‘itch-and-scratch’ cycle, which predisposes to skin excoriation, abrasion and bacterial
infections. Infestations with mites (eg scabies) are also possible, and specific investigation is needed to distinguish
these infestations.
It is important to be aware of the public health implications of these potentially infectious conditions to carers, family
members and/or other aged-care residents.

Allergic reactions and the skin

As with any age, systemic allergies may present with skin manifestations in older people. The risks of skin allergic
manifestations increases in older patients on multiple drug therapies.
Drug allergies present with a broad range of skin manifestations ranging from non-specific morbilliform erythema or
urticaria to the more severe erythema multiforme, Stevens–Johnson syndrome or toxic epidermal necrolysis. 18

Systemic illness and the skin

Diabetes, liver disease, thyroid disease, connective tissue disorders, and autoimmune and vasculitic illnesses may all
present with skin manifestations. Deficiency states (eg iron, zinc, vitamin C or B-group vitamins) and general
malnutrition may present initially with skin signs.

Recognition of certain conditions (eg dermatomyositis, bullous pemphigoid) with their peak incidence in older people
can lead to prompt diagnoses and effective treatment.
Paraneoplastic skin syndromes and their manifestations should also be considered in older people.
Necrobiosis lipoidica and acanthosis nigricans are not uncommon in those who have diabetes, and should be
recognised. Difficult to control flexural or mucocutaneous candidiasis should raise the question of diabetes and
zoster, and especially if severe or extensive, may indicate immune impairment.

Drug therapy in older people

Older people who are on multiple medications and those with chronic illness (especially renal impairment) are at
increased risk of interactions with medication-induced and drug-induced skin reactions.

Some associations are obvious (eg urticaria with aspirin) or severe reactions (eg Stevens–Johnson syndrome to
sulphur-based medications or allopurinol). For others, the cause is less obvious, such as a morbilliform
hypersensitivity rash in a patient on multiple medications, where it can be difficult to identify the trigger. Careful
history taking may assist in the definition of these reactions.
Some medications also cause problems with the skin because of their modes of action. For example, diuretics and
statins may dry the skin; chemotherapy and immunosuppressants, because of reduced immune surveillance,
increase skin cancer and infections.
6 RACGP aged care clinical guide (Silver Book) Part A. Dermatology

Conclusion
Skin problems and symptoms are common in older people. The signs of skin ageing, sun damage and changes in
how older skin reacts can alter how skin problems present and need to be considered. Older people are at increased
risk of impaired heat regulation, increased infections, reduction in barrier functions and poor-healing wounds. Good
nutrition with an adequately balanced diet is important in promoting good skin health. Skin protection, avoidance of
irritants and moisturisation is key with the regular use of emollient lotions, creams and ointments. Skin moisturisation
improves the skin-barrier function and improves quality of life by reducing itch and maintenance of skin integrity.

Appendix 1. Fitzpatrick skin types

Skin type Typical features Tanning ability
I Pale white skin, blue/green eyes, blond/red hair Always burns, does not tan

II Fair skin, blue eyes Burns easily, tans poorly

III Darker white skin Tans after initial burn

IV Light brown skin Burns minimally, tans easily

V Brown skin Rarely burns, tans darkly easily

VI Dark brown or black skin Never burns, always tans darkly

Appendix 2. Levine method swab culture19

1. Cleanse wound with normal saline
2. Remove/debride nonviable tissue
3. Wait 2–5 minutes
4. If ulcer is dry, moisten swab with sterile normal saline
5. Culture the healthiest-looking tissue in the wound bed
6. Do not culture exudate, pus, eschar or heavy fibrous tissue
7. Rotate the end of the sterile alginate-tipped applicator over a 1 cm2 area for five seconds
8. Apply sufficient pressure to swab to cause tissue fluid to be expressed
9. Use sterile technique to break tip of swab into collection device designed for quantitative cultures

References
1. MedlinePlus. Aging changes in skin. Bethesda, MD: MedlinePlus, 2019. Available at https://medlineplus.gov/ency/article/004014.htm
[Accessed 12 August 2019].

2. Chinniah N, Gupta M. Pruritus in the elderly – A guide to assessment and management. Aust Fam Physician 2014;43(10):710–13.
Available at www.racgp.org.au/afp/2014/october/pruritus-in-the-elderly-%E2%80%93-a-guide-to-assessment-and-management
[Accessed 12 August 2019].

3. Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI) – A simple practical measure for routine clinical use. Clin Exp Dermatol
1994;19(3):210–16.

4. Baker C, Mack A, Cooper A, et al. Treatment goals for moderate to severe psoriasis: An Australian consensus. Australas J Dermatol
2013;54(2):148–54.

5. George JN, Aster RH. Drug-induced thrombocytopenia: Pathogenesis, evaluation, and management. Hematology Am Soc Hematol
Educ Program 2009:153–58.

6. American Academy of Dermatology. What causes our skin to age? Rosemont, IL: AAD, 2019. Available at www.aad.org/public/skin-
hair-nails/anti-aging-skin-care/causes-of-aging-skin [Accessed 12 August 2019].

7. Australian Medicines Handbook. AMH aged care companion. Adelaide: AMH, 2018.

8. Millington GWM, Collins A, Lovell CR, et al. British Association of Dermatologists’ guidelines for the investigation and management
of generalized pruritus in adults without an underlying dermatosis, 2018. Br J Dermatol 2018;178(1):34–60.

9. Yosipovitch G, Bernhard GD. Chronic pruritus. N Engl J Med 2013;368:1625–34.

 RACGP aged care clinical guide (Silver Book) Part A. Dermatology 7

10. Cancer Council Australia. Clinical practice guide: Basal cell carcinoma, squamous cell carcinoma (and related lesions) – A guide to
clinical management in Australia. Sydney: Cancer Council Australia, 2008. Available at
https://wiki.cancer.org.au/australiawiki/images/3/31/Final_2008_Guidelines_Basal_cell_carcinoma_Squamous_cell_carcinoma.pdf
[Accessed 12 August 2019].

11. Cancer Council Australia. Clinical practice guidelines for the diagnosis and management of melanoma. Sydney: Cancer Council
Australia, 2016. Available at https://wiki.cancer.org.au/australia/Guidelines:Melanoma [Accessed 12 August 2019].

12. Sussman G. Ulcer dressings and management. Aust Fam Physician 2014;43(9):588–92. Available at
www.racgp.org.au/afp/2014/september/ulcer-dressings-and-management [Accessed 12 August 2019].

13. European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers:
Clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel, 2009.

14. Ulcer and Wound Management Expert Group. Therapeutic guidelines: Ulcers and wound management. In: eTG Complete [Internet]
Melbourne: Therapeutic Guidelines Ltd, 2018.

15. Elliott D, The Bluebelle Study Group. Developing outcome measures assessing wound management and patient experience: A mixed
methods study. BMJ Open 2017;7:e016155.

16. International Wound Infection Institute. Wound infection in clinical practice. London: IWII, 2016.

17. National Institute for Health and Care Excellence. Varicose veins: Diagnosis and management. London: NICE, 2013. Available at
www.nice.org.uk/guidance/cg168 [Accessed 12 August 2019].

18. Smith W. Adverse drug reactions: Allergy? Side-effect? Intolerance? Aust Fam Physician 2013;42(1–2):12–16. Available at
www.racgp.org.au/afp/2013/januaryfebruary/adverse-drug-reactions [Accessed 12 August 2019].

19. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention
and treatment of pressure ulcers: Clinical practice guidelines. Osborne Park, WA: Cambridge Media, 2014. Available at
www.internationalguideline.com [Accessed 12 August 2019].
 RACGP aged care clinical
guide (Silver Book)
5th edition
Part A. Mental health

General principles
• Ageing is a significant time of adjustment and change, where depression and anxiety can be common.

• Restoration of social connectedness is highly beneficial to long-term care and independence.

• Suicidal ideation and attempts have increased frequency in older populations.

• Psychological support (eg counselling, cognitive behavioural therapy) can be beneficial.

• Psychoactive pharmaceuticals need to be used with care in older patients, and need to be regularly
reviewed.

Practice points
Practice points References Grade
Access to clinical and non-clinical services can help support older 2 Consensus-based
people with their mental health recommendation
Tailor activities and programs that aim to address social isolation to 3, 4 Consensus-based
individual patients recommendation
Management of loss and grief may help to prevent older people 5 Consensus-based
from developing depression, or worsening their condition recommendation
Diagnose depression using validated screening and assessment 7, 8 Consensus-based
tests recommendation
Manage depression and anxiety disorders using an individualised 9 Consensus-based
approach that is tailored to the patient’s needs recommendation
Establish those at the highest risk of suicide in the immediate future 27 Consensus-based
who have the intention to end their life, a specific plan, the means recommendation
to carry out the plan and a time frame
2 RACGP aged care clinical guide (Silver Book) Part A. Mental health

Consider adjunct psychological treatments for bipolar disorders 31 Consensus-based

along with pharmacological treatments recommendation
Antipsychotic medication is the first-line treatment in schizophrenia; 37, 38 Consensus-based
cognitive behavioural therapy has been found to aid in the recommendation
management of patients with persistent auditory hallucinations

Introduction
Mental health is a vital component of an individual’s overall health and welfare, and has a strong effect on physical
health. Statistics show that almost half of all Australians will experience a mental health condition at some stage in
their lives. 1 It is important to reassure the patient that help and support are available to them, whether in general
practice or through other support programs.

It is important to recognise that some subpopulations of older people, including Aboriginal and Torres Strait Islander
peoples, veterans, and culturally and linguistically diverse peoples, experience much higher rates of mental health
conditions. The management of mental health in these patients needs to be tailored and individualised.
The purpose of this chapter is not to list all of the potential mental health conditions that older people experience.
Rather, it will highlight some of the more prevalent mental health conditions, including depression, anxiety disorder,
suicide, bipolar and schizophrenia, and provide information regarding their diagnosis and management.

Clinical context
Good mental health is a significant component of healthy ageing, and comprises psychological, biological and/or
social and cultural factors. 2 Appropriate access to effective clinical and non-clinical services can help support older
people with their mental health.

Social isolation and loneliness

Evidence is increasingly illustrating that social isolation is a major contributor of ill health and early mortality. 3 Social
isolation needs to be a focus of general practitioner (GP) consultations in order to prevent, minimise and manage
patients experiencing social isolation, especially those with a mental health condition. 4
Social isolation is an issue that can affect individuals of all ages and does not discriminate against older people;
however, it significantly affects older people with mental health conditions. This problem is compounded, as older
people with mental health conditions may be less likely to participate in community activities and/or have mobility
issues or health conditions.
Activities and programs that aim to address the issue of social isolation need to be tailored to each individual patient
in their environmental setting, whether in a residential aged care facility (RACF) or the community.

Loss and grief

Experiencing loss and grief is a major issue that affects people of all ages; however, this is often amplified in the
older population group. For older people living with mental health conditions, loss is often related to independence,
status, death of family members and friends, and financial stability. The addition of loss and grief on top of pre-
existing mental health conditions can complicate the management of the older person. 5
GPs, RACF staff and nursing staff need to be aware of, and acknowledge, the effects of loss and grief in older
people. Appropriate management of loss and grief may help to prevent older people from developing depression, or
worsening their condition.

Often there are no signs or symptoms that an older person is experiencing loss and grief, and it can manifest as: 6

• crying or a reluctance to cry

• changing eating habits

• losing interest in family, friends and hobbies

 RACGP aged care clinical guide (Silver Book) Part A. Mental health 3

• difficulty sleeping

• difficulty concentrating

• difficulty making decisions.

In practice
The UK’s National Health Service (NHS) encourages health and medical practitioners to recommend the Five steps
to mental wellbeing (Box 1) to all patients who may be experiencing a mental health condition.

Box 1. NHS’ Five steps to mental wellbeing

Encourage all patients to:

• Be active – find an activity you enjoy

• Keep learning – for example, a new skill

• Be giving to others – acts of kindness can improve mental health

• Take notice – be ‘mindful’ of the present moment

• Stay connected – make an effort to develop relationships with family and friends and colleagues.

Safety considerations
Consideration must be given to the safety of older people who may be prescribed pharmacological treatments for
their mental health (eg antidepressants, antipsychotics). Consider the following:

• Close monitoring of effectiveness and side effects

• Appropriate pathology testing

• Falls risk (refer to Part A. Falls)

• Increased risk of bleeding with selective serotonin reuptake inhibitor (SSRIs) and serotonin and norepinephrine
reuptake inhibitors (SNRIs) when combined with other medicines known to increase gastrointestinal bleeding risk

• Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

• Use in people with cardiac disease

– QT prolongation

• Switching between antidepressants

• Switching between antipsychotics

• Serotonin syndrome

• ‘Start low and go slow’

• Use of combinations of antidepressants is not well supported by the literature

Depression
Depression extends beyond low mood, and is a serious mental health condition that has an effect on every aspect of
the older person’s life. An estimated 10–15% of older people aged ≥65 years are thought to experience depression, 7
and this figure reaches as high as 50% in those living in an RACF. 8
Depression is often under-detected and under-diagnosed in older people, as its symptoms (eg sleeping, memory and
concentration issues) are often mistakenly attributed to the normal part of ageing.
Older people who are lonely and do not have appropriate social and support networks are at a significant risk of
developing mental health conditions such as depression. This is also the case with other physical illnesses,
especially as the older person becomes more dependent on others for activities of daily living, leading to a loss of
independence and dignity.
4 RACGP aged care clinical guide (Silver Book) Part A. Mental health

Diagnosis
The diagnosis of depression in older people may include screening and assessment tests, such as the following:

• Geriatric Depression Scale – available and validated in multiple languages and countries. Used to identify
depression in older people in hospitals, RACFs and community settings. 9

• Cornell Scale for Depression in Dementia – designed for the assessment of depression in older people with
dementia who can at least communicate basic needs. It has been tested for reliability, sensitivity and validity on
patients in hospitals, RACFs and community settings.9

• Psychogeriatric Assessment Scales – designed to gather information on the major psychogeriatric disorders:
dementia and depression.

Management
The management of depression in older people needs to be individualised and tailored to the patient’s needs.
Management may include: 10

• lifestyle changes (eg diet, physical exercise, social support) to prevent and treat symptoms of depression

• psychological treatments such as cognitive behavioural therapy (CBT), interpersonal therapy (IPT) and
reminiscence therapy

• pharmacological treatments (antidepressant medication) along with psychological treatments; however, it is

important to consider the duration of treatment and potential side effects. For most older patients, it is important to
consider non-pharmacological strategies before considering pharmacological treatments.

Anxiety disorder
Anxiety disorders are a group of mental health conditions that include:

• generalised anxiety disorder

• phobias (eg social, agoraphobia, claustrophobia)

• panic disorder

• obsessive compulsive disorder

• post-traumatic stress disorder.

An estimated one in four people in the population will have an anxiety disorder that requires treatment at some time
in their life, and another 25% will have less severe anxieties (eg fear of spiders, snakes). Anxiety disorders are
common among older people; however, the prevalence is less common than for older people in RACFs. 11
The prevalence rates of anxiety disorders among older people are 1.2–15% in community samples and 1–28% in
clinical samples of older adults.11
It is important to note that not all experiences of anxiety and fear are considered anxiety disorders. It can become a
problem when the patient’s experience becomes excessive and irrational, and the anxiety begins to interfere with
activities of daily living.

Diagnosis
Figure 1 is a flowchart that may assist in the diagnosis of anxiety disorders. Anxiety-specific tools and questionnaires
may assist with the diagnosis of anxiety disorders, including the following:

• Depression Anxiety Stress Scales-21 (DASS21) – shorter version of the 42-item DASS that was designed to
measure three related negative emotional states of depression, anxiety and tension/stress.

• Kessler 10 (K10) questionnaire – a 10-item questionnaire to measure distress based on questions about anxiety
and depressive symptoms in the past four weeks.
 RACGP aged care clinical guide (Silver Book) Part A. Mental health 5

Figure 1. Differential diagnosis of anxiety disorders 12

Reproduced with permission from Kyrios M, Moulding R, Nedeljkovic M. Anxiety disorders: Assessment and management in general
practice. Aust Fam Physician 2011;40(6):370–74.

Management
The management of anxiety disorders in older people needs to be individualised and tailored to the patient’s needs.
Management may include:

• psychoeducation (education about the nature of anxiety, its purpose and how it can present is important when
dealing with someone with any anxiety disorder)
6 RACGP aged care clinical guide (Silver Book) Part A. Mental health

• psychological treatments (eg CBT has been found to be at least as effective as medication for anxiety
disorders) 13,14

• pharmacological treatments – SSRIs and SNRIs are the first-line pharmacological agents used to treat anxiety
disorders. 15 Benzodiazepines should only be used for a short time frame, and only when anxiety is severe and
disabling, or causing the patient unacceptable distress; GPs need to be aware of the associated adverse effects
(especially falls in older people). The long-term use of benzodiazepines should only be considered when both
psychological and pharmacological treatments have failed, and once specialist review have been sought. 16
Despite the widespread, concurrent use of CBT and pharmacological treatments, there has been no evidence to
suggest that concurrent use is superior to either treatment alone in the long term. 17, 18

Suicide
In 2000–13, an estimated 140 residents in RACFs took their own lives. 19 Studies have found that older men with
depression entering RACFs are at the greatest risk of suicide, and the system is not equipped to support these
residents. Older people aged ≥65 years, especially men, have one of the highest rates of suicide of all age groups in
Australia. 20 The suicide rate of men aged ≥85 years is more than double that of men aged <35 years, and around
seven times higher than that in women of all ages. 21

Diagnosis
It is important to complete a risk assessment of patients who may be contemplating suicide. Some of the risk factors
for suicide to consider include: 22,23,24,28

• previous suicide attempt/s or deliberate self-harm

• older age

• substance abuse

• low or limited social support

• male gender

• Aboriginal and Torres Strait Islander peoples 25

• being widowed 26

• chronic and terminal medical illness

• the 12 months following discharge from a psychiatric hospital

• women experiencing intimate partner violence

• lesbian, gay and bisexual, transgender, intersex, queer identification

• a feeling of hopelessness or absolute despair

• having lost a family member to suicide

• living alone or in prison 27

• mental disorders, especially mood disorders, and alcohol and drug abuse.
There is currently limited evidence on the efficacy and validity of screening tools for suicide risks. 28 People who are at
the highest risk of suicide in the immediate future are those who have: 29

• the intention to end their life

• a specific plan

• the means to carry out the plan

• a time frame.
Questions to consider during assessment should include:

• Suicidal thinking – if suicidal thinking is present, how frequent and persistent is it?

• Plan – if the person has a plan, how detailed and realistic is it?
 RACGP aged care clinical guide (Silver Book) Part A. Mental health 7

• Lethality – what method has the person chosen and how lethal is it?

• Means – does the person have the means to carry out the method?

• Past history – has the person ever planned or attempted suicide?

• Suicide of family member or peer – has someone close to the person attempted or completed suicide?
It is important to note that this is a delicate and sensitive conversation, and care needs to be taken when assessing
the risk. If you believe a patient is at high risk of suicide based on your clinical judgement, seek help immediately by
calling 000 (police, ambulance).

Management
Figure 2 lists some of the management options for patients with suicidal risk or behaviour, with additional treatment
options for those with comorbid mental health conditions.

Figure 2. Acute management of patients with suicidal risk or behaviour 30

Behaviour Treatment Notes

Patients with suicidal risk or First Hospitalisation or outpatient

behaviour monitoring
Adjunct Psychotherapy
Adjunct Psychosocial interventions
Adjunct Treatment of physical injury if
suicidal attempt
With bipolar Plus Mood stabiliser
With schizoaffective disorder Plus Antipsychotic and/or mood stabiliser
With depression Plus Selective serotonin reuptake
inhibitor (SSRI)
With personality disorder Plus SSRI
With substance abuse Plus Detoxification and monitoring

The General Practice Mental Health Standards Collaboration (GPMHSC) has developed Suicide prevention and first
aid: A resource for GPs to provide advice to GPs about mental health first aid for suicide prevention. Beyond Blue
has also developed resources for patients who have attempted suicide: Finding your way back.

Bipolar
An estimated 1% of the Australian community has bipolar disorder, where the patient is more likely to experience
broken relationships and make suicide attempts than even those with unipolar depression. 31 Up to 25% of all patients
with bipolar are older people, and the prevalence will increase as the population continues to age. 32

Diagnosis
The main characteristic of bipolar disorder is the tendency to swing between the two contrasting ‘poles’ of elevated
mood (ie hypomania or mania [Box 2] and depression), with a return to largely normal functioning in between these
episodes. 33
8 RACGP aged care clinical guide (Silver Book) Part A. Mental health

Box 2. Symptoms of mania and hypomania (symptoms need to be present for at least four days for
hypomania and seven days for mania)

• Abnormally elevated or euphoric mood, frequently associated with an increased tendency to irritability

• Increased energy and activity (more ‘wired’)

• Reduced need for sleep (as distinct from insomnia)

• An inflated sense of one’s own abilities (grandiosity)

• Disinhibited behaviour – increased sexual drive; increased spending or excessive generosity; tendency to make
overly frank comments about others

• Increased subjective speed of thoughts (‘my thoughts are too quick for my tongue to keep up with’); more
talkative; speaking more loudly

• Increased distractibility – reduced ability to focus and complete tasks (despite having many plans or projects)

• Enhanced perceptual experiences – for example, sounds are more harmonious, colours richer than usual

Reproduced with permission from Mitchell PB. Bipolar disorder. Aust Fam Physician 2013;42(9):616–19.

Management
There is growing evidence that adjunct psychological treatments with pharmacological treatments can help more than
just pharmacological treatments alone. 34 Pharmacological treatments include:16,33,35,36

• lithium

• anticonvulsants

• first-generation antipsychotics

• second-generation antipsychotics.

Schizophrenia
Schizophrenia affects an estimated 30,000 Australians, 37 with a median lifetime risk of 7.2 per 1000 in the
population. 38 Symptoms of schizophrenia include delusions, hallucinations, flatness of affect, poverty of speech or
incoherence of speech; and may also include mood symptoms, cognitive problems and movement disorders. 39

Diagnosis
The management of older people with schizophrenia and depressive symptoms must first include a reassessment of
the diagnosis to ensure symptoms are not due to a comorbid condition, metabolic problems or medications. 40
The Diagnostic and statistical manual of mental disorders, fifth edition (DSM-5) notes that a diagnosis of
schizophrenia can only be made when two or more of the following has occurred for at least one month: 41

• Delusions

• Hallucinations

• Disorganised speech

• Grossly disorganised or catatonic behaviour

• Negative symptoms (eg diminished emotional expression)

In addition, at least one of the above must include one of the following:41

• Impairment in work, interpersonal relations or self-care for a significant period

• Last for a continuous period of at least six months

• Schizoaffective disorder and bipolar or depressive disorder with psychotic features have been ruled out
 RACGP aged care clinical guide (Silver Book) Part A. Mental health 9

Management
Pharmacological treatment, psychological treatments and lifestyle changes are vital in the management of older
patients with schizophrenia and depressive symptoms. Management may include:40

• pharmacological treatment – antipsychotic medication is the first-line treatment in schizophrenia by maintaining

symptom control and minimising exacerbations of illness. 42 GPs need to be aware of the side effects, and
manage these adverse events accordingly.

• psychological treatments – specific treatments can help in the management of patients with schizophrenia; CBT
has been found to aid in the management of patients with persistent auditory hallucinations. 43

• lifestyle changes, including social and vocational rehabilitation for the establishment or return of functional
capacity in activities of daily living, exercise 44 and diet.

Patient resources
• Lifeline – 13 11 14

• MensLine Australia (for men of any age) – 1300 789 978

• Suicide Call Back Service – 1300 659 467

• Healthdirect Australia – 1800 022 222

• Beyond Blue – 1300 224 636

References
1. Australian Bureau of Statistics. National Survey of Mental Health and Wellbeing: Summary of results. Canberra: ABS, 2009.

2. World Health Organization. Mental health and older adults. Factsheet no. 381. Geneva: WHO, 2013.

3. Franklin A, Tranter B. AHURI Essay Housing, loneliness and health. Melbourne: Australian Institute of Housing and Urban Research
Institute, 2011.

4. House, JS. Social isolation kills, but how and why? Psychosom Med 2001;63:273–74.

5. Grimby A. Bereavement among elderly people: Grief reactions, post‐bereavement hallucinations and quality of life. Acta Psychiatr
Scand 1993;87(1):72–80.

6. Hashim SM, Eng TC, Tohit N, Wahab S. Bereavement in the elderly: The role of primary care. Ment Health Fam Med 2013;10(3):159–
62.

7. Haralambous B, Lin X, Dow B, Jones C, Tinney J, Bryant C. Depression in older age: A scoping study. Melbourne: National Ageing
Research Institute, 2009.

8. Australian Institute of Health and Welfare. Depression in residential aged care 2008–2012. Canberra: AIHW, 2013.

9. Kørner A, Lauritzen L, Abelskov K, et al. The Geriatric Depression Scale and the Cornell Scale for Depression in Dementia. A validity
study. Nord J Psychiatry 2006;60(5):360–64.

10. Kok RM, Reynolds CF 3rd. Management of depression in older adults: A review. JAMA 2017;317(20):2114–22.

11. Wolitzky-Taylor KB, Castriotta N, Lenze EJ, Stanley MA, Craske MG. Anxiety disorders in older adults: A comprehensive review.
Depress Anxiety 2010;27(2):190–211.

12. Kyrios M, Moulding R, Nedeljkovic M. Anxiety disorders: Assessment and management in general practice. Aust Fam Physician
2011;40(6):370–74.

13. Olatunji BO, Cisler JM, Deacon BJ. Efficacy of cognitive behavioral therapy for anxiety disorders: A review of meta-analytic findings.
Psychiatr Clin North Am 2010;33:557–77.

14. Deacon BJ, Abramowitz JS. Cognitive and behavioral treatments for anxiety disorders: A review of meta-analytic findings. J Clin
Psychol 2004;60:429–41.

15. Ravindran LN, Stein MB. The pharmacologic treatment of anxiety disorders: A review of progress. J Clin Psychiatry 2010;71:839–54.

16. Psychotropic Expert Group. Anxiety and associated disorders. Melbourne: Therapeutic Guidelines, 2019.

17. Foa EB, Franklin ME, Moser J. Context in the clinic: How well do cognitive behavioral therapies and medications work in combination?
Biol Psychiatry 2002;52:987–97.

18. Hofmann SG, Sawyer AT, Korte KJ. Is it beneficial to add pharmacotherapy to cognitive-behavioral therapy when treating anxiety
disorders? A metaanalytic review. Int J Cogn Ther 2009;2:160–75.
10 RACGP aged care clinical guide (Silver Book) Part A. Mental health

19. Murphy BJ, Bugeja LC, Pilgrim JL, Ibrahim JE. Suicide among nursing home residents in Australia: A national population-based
retrospective analysis of medico-legal death investigation information. Int J Geriatr Psychiatry 2018;33(5):786–96.

20. World Health Organization. Preventing suicide: A global imperative. Geneva: WHO, 2014. Available at
www.who.int/mental_health/suicide-prevention/world_report_2014/en [Accessed 12 August 2019].

21. Australian Bureau of Statistics. Causes of death, Australia, 2013. Canberra: ABS, 2015. Available at
www.abs.gov.au/ausstats/[email protected]/Lookup/by%20Subject/3303.0~2013~Main%20Features~Suicides~10004 [Accessed 12 August
2019].

22. Siu AL, US Preventive Services Task Force. Screening for depression in adults, US Preventive Services Task Force recommendation
statement. JAMA 2016;315(4):380–87.

23. Gaynes B N, West SL, Ford CA, Frame P, Klein J, Lohr KN. Screening for suicide risk in adults: A summary of the evidence for the US
Preventive Services Task Force. Ann Intern Med 2004;140(10):822–35.

24. LeFevre ML, US Preventive Services Task Force. Screening for suicide risk in adolescents, adults, and older adults in primary care:
US Preventive Services Task Force recommendation statement. Ann Intern Med 2014;160(10):719–26.

25. Large MM, Nielssen OB. Suicide in Australia: Meta-analysis of rates and methods of suicide between 1988 and 2007. Med J Aust
2010;192(8):432–37.

26. World Health Organization, Department of Reproductive Health and Research London School of Hygiene and Tropical Medicine,
South African Medical Research Council. Global and regional estimates of violence against women. Prevalence and health effects of
intimate partner violence and non-partner sexual violence. Geneva: WHO, 2013.

27. King M, Semlyen J, Tai SS, et al. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and
bisexual people. BMC Psychiatry 2008;8:70.

28. US Preventive Services Task Force. The guide to clinical preventive services 2014: Recommendations of the US Preventive Services
Task Force. Rockville, MD: US Preventive Task Force, 2014.

29. Eyers K, Parker G, Brodaty H. Managing depression growing older: A guide for professionals & carers. Melbourne: Allen & Unwin,
2012.

30. BMJ Best Practice. Suicide risk management. London: BMJ, 2018. Available at https://bestpractice.bmj.com/topics/en-us/1016
[Accessed 12 August 2019].

31. Mitchell PB, Johnston AK, Frankland A, et al. Bipolar disorder in a national survey using the World Mental Health Version of the
Composite International Diagnostic Interview: The impact of differing diagnostic algorithms. Acta Psychiatr Scand 2013;127:381–93.

32. Sajatovic M, Blow FC, Ignacio RV, Kales HC. Age-related modifiers of clinical presentation and health service use among veterans
with bipolar disorder. Psychiatr Serv 2004;55:1014.

33. Mitchell PB. Bipolar disorder. Aust Fam Physician 2013;42(9):616–19.

34. Geddes JR, Miklowitz DJ. Treatment of bipolar disorder. Lancet 2013;381:1672–82.

35. Jacobson SA. Clinical manual of geriatric psychopharmacology. 2nd edn. Washington, DC: American Psychiatric Publishing, 2014.

36. Australian Medicines Handbook. AMH Aged care companion. Adelaide: AMH, 2018.

37. Morgan V, Waterreus A, Jablensky A, et al. People living with psychotic illness in 2010: The second Australian national survey of
psychosis. Aust N Z J Psychiatry 2012;46:735–52.

38. McGrath J, Saha S, Chant D, Welham J. Schizophrenia: A concise overview of incidence, prevalence, and mortality. Epidemiol Rev
2008;30:67–76.

39. Wing J. A simple and reliable subclassification of chronic schizophrenia. J Ment Sci 1961;107:862–75.

40. Felmet K, Zisook S, Kasckow JW. Elderly patients with schizophrenia and depression: Diagnosis and treatment. Clin Schizophr Relat
Psychoses 2011;4(4):239–50.

41. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th edn. Washington, DC: APA, 2013.

42. Lehman AF, Lieberman JA, Dixon LB, et al. American Psychiatric Association Practice Guidelines; Work Group on Schizophrenia.
Practice guideline for the treatment of patients with schizophrenia. Am J Psychiatry (2nd edn) 2004;161 Suppl 2:1–56.

43. Mueser K, Deavers F, Penn D, et al. Psychosocial treatments for schizophrenia. Annu Rev Clin Psychol 2013;9:465–97.

44. Schweewe T, Backx F, Takken T, et al. Physical therapy improves mental and physical health in schizophrenia: A randomized
controlled trial. Acta Psychiatr Scand 2013;127:464–73.
 RACGP aged care clinical
guide (Silver Book)
5th edition
Part A. Infection and sepsis

General principles
• Infection and sepsis are common causes of morbidity and mortality in the aged care population.
• Clinical presentations of infection and sepsis are often atypical.
• The decision to treat locally or transfer is dependent on clinical urgency, patient context and geographical
location.
• Antimicrobial stewardship is a critical aspect of infection and sepsis care.
• There are particular challenges with infection and sepsis in the residential aged care facility environment.

Practice points
Practice points References Grade
Prevention of infections via prophylactic vaccination is recommended, including 11, 12 Consensus-based
pneumococcus vaccine and annual influenza vaccination recommendation
Ensure appropriate reminder systems are in place for regular, specific – Consensus-based
prophylaxis recommendation
Within an enclosed healthcare facility, general practitioners have an important – Consensus-based
role in endorsing infection control procedures and promulgating the herd recommendation
immunity concept
Use the correct antibiotic for the correct indication; use the correct dose for the 13 Consensus-based
correct time recommendation
If the use of an antibiotic is deemed urgent, it may be appropriate to commence 20 Consensus-based
an antibiotic reflecting a previous documented system-specific infection, and recommendation
known sensitivities, while waiting for the microbiology result
Consider a broad range of other differential diagnoses when making an – Consensus-based
assessment for infection and sepsis recommendation
2 RACGP aged care clinical guide (Silver Book) Part A. Infection and sepsis

Depending on the individual context, patients with high-risk criteria for sepsis 7 Consensus-based
must be urgently assessed with a view to immediate transfer to hospital recommendation
Depending on the clinical scenario, when dealing with sepsis: 20 Consensus-based
recommendation
• swabs should be taken
• results reviewed when available
• antibiotics prescribed for the shortest possible duration and given by the
most appropriate dosing regimen

A mid-stream urine is recommended prior to commencing treatment for urinary 14 Consensus-based

tract infections (UTIs) recommendation
Treating any underlying structural abnormalities and/or removal of indwelling 13 Consensus-based
catheter will reduce UTI frequency recommendation
In the context of tissue infection, persistent localised pain is a red flag 16 Consensus-based
recommendation
Treatment of gastrointestinal infections is via rehydration principles, and 17–19 Consensus-based
symptomatic support as required recommendation

Introduction
Infection and sepsis (ie life-threatening organ dysfunction) are responsible for nearly one third of all-cause mortalities
in patients aged 65 years and over, and nearly 90% of deaths from pneumonia are in this patient population. 1
Additionally, sepsis is known to be associated with advanced age, and chronic complex comorbidities influence and
increase risk.
There are significant changes to homeostasis in all organ systems as the body ages, and the immune system is no
exception. 2 With advanced age, the immune system is impaired both quantitatively and qualitatively, which is
reflected by an increased susceptibility to infection, and a delayed or ineffective recovery.
A protracted illness is not uncommon when an older person experiences infection or sepsis, with the probability of
never fully regaining premorbid functional status. Therefore, a higher level of care is not uncommon as a
consequence. Readmission to hospital after an episode of sepsis within 30 days is about 30% (Box 1). 3

Box 1. Known risk factors for infection 4,5

• Immobility: ‘dangers’ of going to bed

• Impaired mobility
• Age-related impaired ‘barrier changes’ (eg skin, lungs, gastrointestinal tract)
• Poor oral hygiene and consequent poor nutritional status
• Impaired swallowing mechanism
• Gender-related factors
– in women: lack of oestrogen in post-menopausal women predisposes to urinary tract infections (UTIs)
– in men: benign prostatic hyperplasia contributes to urinary stasis and consequent UTIs
• Permanent indwelling catheters, and/or other types of implants or prosthesis
• Recognised syndromes of an altered immune state, including iatrogenic factors: medication review is mandatory
(refer to Part A. Medication management)
• The presence of dementia itself is associated with a 50% higher risk of sepsis (refer to Part A. Dementia)

Institutional care (ie close living proximity) also brings with it its own unique susceptibility to infections. 6 Responsibility
for the prevention of common infections via prophylactic vaccination (eg influenza, pneumococcus, zoster vaccines)
for patients in residential aged care facilities (RACFs) and those living in the community falls within the realm of
general practitioners (GPs).
 RACGP aged care clinical guide (Silver Book) Part A. Infection and sepsis 3

It is important to note that there may also be a suboptimal response to vaccines in older patients as a consequence
of decreased antibody efficiency and changes in cellular and humoral immunity. It is important to ensure that
appropriate reminder systems are in place to ensure regular specific prophylaxis.
GPs can also provide support and advice for infection control procedures within the RACF environment. The
endorsement of staff and volunteers’ vaccination will have the additional benefit of providing herd immunity.
Collaborative team-based care with allied health professionals can also help to reduce the risk of sepsis. For
example, a poor nutritional status can have adverse effects on an already compromised immune system.
Pharmacists, dentists, dietitians, physiotherapists, podiatrists, speech pathologists and other allied health
professionals may have an important role to play in providing holistic care.

Clinical context
The clinical presentations of infection or sepsis in older people are multifarious, and the signs are often subtle and
atypical. Other existing comorbidities can precipitate a cascade of deterioration (refer to Part A. Multimorbidity).
Cognitive impairment adds yet another layer of complexity to an already ambiguous clinical situation. Clinical
appraisal should be systematic and complete.
The National Institute for Health and Care Excellence (NICE) has created an assessment guideline and a risk
stratification tool to aid the management of sepsis (Figure 1).

A history of new-onset changed behaviour (eg delirium spectrum; refer to Part A. Dementia and Part A. Behavioural
and psychological symptoms of dementia) or an acute change in functional ability (eg sudden increase in falls; refer
to Part A. Falls) are very common presentations of an infection syndrome in older people.
Of particular note is that fever, the cardinal sign of infection, is absent in 30–50% of frail older adults. A change from
baseline temperature is important to note as the response to sepsis can be blunted.

Figure 1. Sepsis: Assessment guideline and risk stratification tool 7

4 RACGP aged care clinical guide (Silver Book) Part A. Infection and sepsis

Reproduced with permission from National Institute for Health and Care Excellence. Sepsis: Risk stratification tools. London: NICE, 2017.
Available at www.nice.org.uk/guidance/ng51/resources/algorithm-for-managing-suspected-sepsis-in-adults-and-young-people-aged-18-
years-and-over-outside-an-acute-hospital-setting-2551485716 [Accessed 23 August 2019].

The increasing availability of mobile pathology and radiology services may reduce the need for hospital transfer for
diagnosis and treatment. Appropriate point-of-care investigation, if available, may aid diagnosis and management
(eg inflammatory markers, lactate level).
Remember that the classical signs and symptoms of the infectious focus may be absent, and the most common
‘organ’ origins are the respiratory tract, urinary tract, skin and soft tissues, and the gastrointestinal tract (refer to the
lists of signs and symptoms below).
However, it is important to note that there are many other system-specific sources and causes of infection. The GP
should therefore consider a broad range of differential diagnoses when making an assessment. A careful complete
clinical assessment, along with considered investigations, will enhance the diagnostic process. A fever in older
people may, in fact, indicate a non-infective cause (eg polymyalgia rheumatica, acute gout).

This clinical scenario and its clinical governance are very much within the skill set of general practice. The decision to
treat locally or transfer is dependent on clinical urgency, patient context and geographical location.
The Hospital in the Home (HITH) phenomenon is having an effect, although the service availability is somewhat
limited and reflects location. The HITH system is designed to assess and treat many ‘hospital patients’ at home, and
includes residents of an RACF. HITHs can safely deliver intravenous antibiotics, antivirals and intravenous fluids to
RACF residents, including those with pneumonia (includes aspiration), cellulitis and uro-sepsis. There is evidence
that outcomes are equivalent to hospital-based care if patient selection is optimised. 8,9,10

Respiratory tract infection

Key features to consider: 11,12

• Respiratory tract infections are a leading cause of death among RACF patients.
• Respiratory tract infections can have a subtle presentation.
• Comorbidities confound and complicate assessment and management (eg co-existing heart failure).
• Pneumonia may be community-acquired or hospital-acquired.
 RACGP aged care clinical guide (Silver Book) Part A. Infection and sepsis 5

• Aspiration pneumonia is common.

• Causative bacteria may differ from the general population.
• Pneumonia severity scores can aide management (eg SMART-COP tool, CORB).6
• Viral infections are still prevalent, and differentiation is problematic.
• 23-valent pneumococcal polysaccharide vaccine (23vPPV) is recommended for the prevention of invasive
pneumococcal disease; vaccination should be done opportunistically. One dose is currently recommended
except for those who have a condition that predisposes them to an increased risk of invasive pneumococcal
disease. 13 It is important to refer to the Department of Health’s Australian immunisation handbook for specific
guidance.
• Initial antibiotic treatment, if deemed necessary, should reflect best practice, as per guidelines. 14

Urinary tract infection

Key features to consider: 15

• Asymptomatic bacteriuria is very common (~50% of RACF patients): screening is not recommended, and a
dipstick urinalysis is useful only to exclude urinary tract infections (UTIs) in patients who have a low pre-test
probability.
• UTIs can have a subtle presentation (classical UTI symptoms are often absent).
• Consider contributing factors (eg localised pathology, other comorbidities, iatrogenic factors).
• Antibiotic resistance is common for multiple reasons, and a mid-stream urine is recommended prior to
commencing treatment.
• Indwelling catheters predispose to bacteriuria: only treat if there are signs of systemic infection.
• Treatment decision will reflect clinical status and antibiotic sensitivities.14
• Treating underlying structural abnormalities and/or removal of indwelling catheter will reduce UTI frequency. 16
• The evidence to support the use of prophylactic antibiotics, cranberry products, or topical oestrogen to prevent
recurrent infections in patients within an RACF is lacking. 17

Skin and soft tissue infection

Key features to consider: 18

• Red-hot skin does not always equate with infection (refer to Part A. Dermatology).
• Skin integrity may be compromised by age and other comorbidities.
• A history of minor trauma is not infrequent.
• Localised simple infection with no signs of systemic spread is common.
• Cellulitis presents as a diffuse spreading area of skin erythema.
• More complicated infections can be necrotising, non-necrotising and/or suppurative or non-suppurative.
• Persistent localised pain is a red flag, and may indicate a rapidly progressive deep soft tissue infection.
• Adhere to antibiotic regimen as per guidelines (eg Therapeutic Guidelines).14

Gastrointestinal infections
Key features to consider: 19,20,21

• Infection control principles are critical because of close proximity living in RACFs.
• Gastrointestinal infections are often caused by norovirus or rotavirus.
• Gastrointestinal infections can have subtle and atypical presentations; dehydration and consequent metabolic
imbalance are common.
• A change in bowel habit in an older patient can reflect multiple other causes (refer to Part A. Faecal
incontinence).
6 RACGP aged care clinical guide (Silver Book) Part A. Infection and sepsis

• Treatment of gastrointestinal infections is via rehydration principles, and symptomatic support as required.
• There are public health implications and notification requirements.
• Antibiotics are rarely required and must reflect the clinical syndrome and relevant microbiology.

Antimicrobial stewardship
Antimicrobial stewardship in RACFs presents a unique challenge, and the current evidence base to guide best
practice is incomplete. It has been estimated that 40–70% of antibiotic prescribing within an RACF is inappropriate,
and antibiotic resistance is increasing. 22 The frequent transfers between healthcare facilities (ie RACF to hospital and
back) exacerbates antibiotic resistance.

There is a high infection burden among older patients in RACFs (ie colonised, infected). It is important that GPs
prescribe in a judicious and prudent manner in order to avoid the increased emergence of multi-drug resistant
microbes, and carefully follow available best-practice guidelines. 23
In general, swabs should be taken if possible, results reviewed when available, and antibiotics prescribed for the
shortest possible duration and given by the most appropriate dosing regimen.12 Maintaining close contact with the
local pathology laboratory is essential, as knowledge of local microbe epidemiology can help decision-making.
Patient context and environment will dictate whether or not to treat.
If the use of an antibiotic is deemed urgent, it may be appropriate to commence an antibiotic reflecting a previous
documented system-specific infection, and known sensitivities, while waiting for the microbiology result.12
Antimicrobials may be prescribed not only by the residents’ GP, but also by locum doctors, nurse practitioners,
specialists, dentists and hospitals. Handovers and contemporaneous records are critical in optimising care if
antimicrobials are prescribed.

The aged care home pharmacist (if available) is well placed to review antimicrobial prescriptions to help minimise
inappropriate or unnecessary antimicrobial use (refer to Part A. Medication management).
The known science underpinning appropriate antibiotic prescribing, along with personal, cultural and societal issues
need to be considered. These include:

• the premorbid clinical status of the patient

• quality-of-life issues
• personal and family beliefs and expectations
• advanced health directives
• whether active antibiotic treatment should be withdrawn when there is lack of clinical response.
Clinical governance within the RACF environment is geographically variable, and may reflect a lack of appropriate
responsibility, resourcing and commitment, which can affect felicitous prescribing.
However, GPs have a deep understanding of pathophysiology and therapeutics, and can therefore drive change and
provide the leadership required to enhance clinical governance and consequent antibiotic stewardship. Cultural and
structural changes are urgently required.
Use the correct antibiotic for the correct indication; use the correct dose for the correct time.14

In practice
General practice remains a clinical relationship specialty. Although episodic care can be part of a GP’s responsibility,
it is the consistent awareness of the context via continuity of care that differentiates general practice from other
medical specialties, and aids individual assessments.6
Contemporaneous quality records and clinical handover are always critical in general practice, but this is especially
the case in the RACF context, specifically for patients whom the GP does not know well, as may well be the case in
the after-hours provision of care.
The medical assessment and management of older patients in RACFs and the community with a potential infection
presents unique challenges, including:

• the clinical presentation

• whether to investigate
 RACGP aged care clinical guide (Silver Book) Part A. Infection and sepsis 7

• whether to treat locally

• whether to transfer.
Knowing the patient and their context can make the management of infections in older patients less problematic.
Respecting the patient and their family’s wishes and expectations remains a critical part of the GP skill set: informed
choice and patient-centred care reflects best practice (refer to Part A. Palliative and end-of-life care).
In the context of infection and potential sepsis, knowledge of local microbiological epidemiology and antibiotic
stewardship are also critical.

Telephone enquiries
In RACFs, telephone enquiries to the GP from the nursing staff regarding possible infection in an older patient are
common. Here, the GP has to make a judgement call based on an initial verbal description (ie collateral history).
Knowing the patient helps, but, periodically, there is no prior contact or context available to the GP. It is therefore
important to consider the following:

• What is the presentation?

• What are the underlying comorbidities?
• What is the past medical history?
• Do we have access to the therapeutic regimen?
• What is the present care level?
• What are the patient and/or family expectations?
• Is there an advanced health directive in place?
Best practice should mean that the GP has access to contemporaneous and up-to-date records; however, individual
RACFs use different software packages, making clinical decisions even more challenging.
The availability of a senior nurse who knows the patient can be invaluable in making the right management decision;
however, the rapid turnover of nursing staff in RACFs adds an additional complexity.

Triaging
Depending on the clinical triage decision made by the GP, and the location of the RACF or patient’s home, a decision
may have to be made to transfer the patient urgently, or for the GP to perform an acute visit for assessment. Most
commonly, the situation is not acute and will require a non-urgent visit and assessment.

With potential signs of severe sepsis (eg persistent hypotension), the GP has to be prepared to visit the patient
urgently to assist in resuscitation and stabilisation prior to transfer to a higher level of care. It is important to note that
each hour of delay in commencing an appropriate antibiotic, if deemed appropriate, increases mortality. 24
For severe sepsis, contrary to the ‘start low, go slow’ approach for the older cohort, if a serious infection is suspected,
and the decision for active treatment made, the first dose antibiotic at the highest level should be administered, within
the known safety level of the drug. 25

References
1. Mouton CP, Bazaldua OV. Common infections in older adults. Am Fam Physician 2001;63(2):257–69. Available at
www.aafp.org/afp/2001/0115/p257.html [Accessed 8 August 2019].

2. Navaratnarajah A, Jackson SHD. The physiology of ageing. Medicine 2017;45(1):6–10. Available at

www.medicinejournal.co.uk/article/S1357-3039(16)30229-8/abstract [Accessed 8 August 2019].

3. Norman BC, Cooke CR, Ely EW, Graves JA. Sepsis-associated 30-day risk-standardized readmissions: Analysis of a nationwide
Medicare sample. Crit Care Med 2017;45(7):1130–37.

4. Asher RAJ. Dangers of going to bed. Br Med J 1947;2:967. Available at www.bmj.com/content/2/4536/967 [Accessed 8 August 2019].

5. Rowe TA. Sepsis in older adults. Infect Dis Clin North Am 2017;31(4):731–42. Available at www.id.theclinics.com/article/S0891-
5520(17)30064-8/fulltext [Accessed 8 August 2019].
8 RACGP aged care clinical guide (Silver Book) Part A. Infection and sepsis

6. The Royal Australian College of General Practitioners. Standards for general practices. 5th edn. East Melbourne, Vic: RACGP, 2017.
Available at www.racgp.org.au/running-a-practice/practice-standards/standards-5th-edition/standards-for-general-practices-5th-ed
[Accessed 8 August 2019].

7. National Institute for Health and Care Excellence. Sepsis: Risk stratification tools. Available at
www.nice.org.uk/guidance/ng51/resources/algorithm-for-managing-suspected-sepsis-in-adults-and-young-people-aged-18-years-and-
over-outside-an-acute-hospital-setting-2551485716 [Accessed 8 August 2019].

8. Montalto M, Chu MY, Spelman T, Ratnam I, Thursky K. The treatment of nursing home acquired pneumonia using a medically intensive
Hospital in the Home service. Med J Aust 2015;203(11):441–42.

9. Montalto M. Hospital in the nursing home: Treating acute hospital problems in nursing home residents using HHU model. Aust Fam
Physician 2001;30(10):1010–12.

10. Montalto M, Shay S, Le A. Evaluation of a mobile X-ray service for elderly residents of residential aged care facilities. Aust Health Rev
2015;39(5):517–21.

11. Infectious Disease Advisor. Community acquired pneumonia guidelines. New York: Infectious Disease Advisor, 2018.

12. Therapeutic Guidelines. Community-acquired pneumonia in adults. Melbourne: eTG, 2019. Available at
https://tgldcdp.tg.org.au/viewTopic?topicfile=community-acquired-pneumonia#toc_d1e1225 [Accessed 8 August 2019].

13. The Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. 9th edn. East Melbourne,
Vic: RACGP, 2015. Available at www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-
guidelines/red-book/preventive-activities-in-older-age/immunisation [Accessed 8 August 2019].

14. Therapeutic Guidelines. Antibiotics. Melbourne: eTG, 2019. Available at

https://tgldcdp.tg.org.au/guideLine?guidelinePage=Antibiotic&frompage=etgcomplete [Accessed 8 August 2019].

15. Jarvis TR, Chan L, Gottlieb T. Assessment and management of lower urinary tract infection in adults. Aust Prescr 2014;37:7–9.
Available at www.nps.org.au/australian-prescriber/articles/assessment-and-management-of-lower-urinary-tract-infection-in-adults
[Accessed 8 August 2019].

16. Nicolle LE. Catheter associated urinary tract infections. Antimicrob Resist Infect Control 2014;3:23.

17. Jarvis TR, Chan L, Gottlieb T. Assessment and management of lower urinary tract infection in adults. Aust Prescr 2014;37(1):7–9.
Available at www.nps.org.au/australian-prescriber/articles/assessment-and-management-of-lower-urinary-tract-infection-in-
adults#treatment [Accessed 8 August 2019].

18. Ramakrishnan K, Salinas RC, Hiugita NIA. Skin and soft tissue infections. Am Fam Physician 2015;92(6):474–83. Available at
www.aafp.org/afp/2015/0915/p474.html [Accessed 8 August 2019].

19. Department of Health. Viral gastroenteritis in residential aged care. Canberra: DoH, 2016. Available at
https://agedcare.health.gov.au/overview/advice-to-the-aged-care-industry/aged-care-entry-record/viral-gastroenteritis-in-residential-
aged-care [Accessed 8 August 2019].

20. Australian Commission on Safety and Quality in Health Care. Antimicrobial stewardship in Australian health care 2018. Sydney:
ACSQHC, 2018. Available at www.safetyandquality.gov.au/our-work/healthcare-associated-infection/antimicrobial-stewardship
[Accessed 8 August 2019].

21. Department of Health. Antimicrobial resistance – Aged care. Canberra: DoH, 2019. Available at www.amr.gov.au/what-you-can-do/aged-
care [Accessed 8 August 2019].

22. Turnidge J. Antimicrobial use and resistance in Australia. Aust Prescr 2017;40:2–3. Available at www.nps.org.au/australian-
prescriber/articles/antimicrobial-use-and-resistance-in-australia [Accessed 8 August 2019].

23. Lim CJ, Stuart RL, Kong DCM. Antibiotic use in residential aged care facilities. Aust Fam Physician 2015;44(4):192–96. Available at
www.racgp.org.au/afp/2015/april/antibiotic-use-in-residential-%E2%80%A8aged-care-facilities [Accessed 8 August 2019].

24. Patterson B. How important is the timing of antibiotics for surviving sepsis. New York: Infectious Disease Advisor, 2018. Available at
www.infectiousdiseaseadvisor.com/sepsis/timing-of-antibiotics-for-surviving-sepsis/article/761995 [Accessed 8 August 2019].

25. Australian Commission on Safety and Quality in Health Care. AURA 2019 at a glance. Canberra: ACSQHC, 2019.
 RACGP aged care clinical
guide (Silver Book)
5th edition
Part A. Falls

General principles
• Regularly assess the older person’s risk of falls (annually for those aged >70 years).
• Identify and manage medical conditions that contribute to falls.
• Recommend interventions to prevent falls.
• Recommend interventions to prevent injury in the event of a fall.
• Involve physiotherapists, occupational therapists, podiatrists, optometrists and audiologists when
appropriate to help minimise falls risk.
• Regularly review medications, including a pharmacist review where appropriate.
• Strength and balance training under the supervision of a physiotherapist is an important intervention.
• Expedite necessary cataract surgery (first-eye cataract surgery).

Practice points
Practice points References Grade
A physiotherapist may be able to determine falls risk and provide 11 Consensus-based
important diagnostic information by undertaking a thorough gait and recommendation
balance assessment, including activities such as Tai Chi, and
balance and functional exercise programs
Consider specific neurological conditions, cardiovascular diseases 3–10 Consensus-based
and vestibular diseases when investigating falls recommendation
Consider pharmacological and non-pharmacological strategies for 11 Consensus-based
the prevention of falls and reduction of injury in the event of a fall recommendation
Conduct a post-fall assessment after an older person has 11 Consensus-based
experienced a fall to identify any injuries, understand what may recommendation
have caused the fall and importantly prevent or reduce the risk of
further falls
2 RACGP aged care clinical guide (Silver Book) Part A. Falls

Introduction
A fall is an event that results in a person coming to rest inadvertently on the ground, floor or other lower level. 1
Physiological parameters (eg reaction time, body sway, quadriceps strength, vibration sense, visual contrast
sensitivity) are significantly impaired in those who experience recurrent falls, compared with those who do not fall.
When an older person falls, the cause is frequently multifactorial, and requires a multidisciplinary approach to
intervention. The risk of falling increases with the number of risk factors as detailed further.

Clinical context
Falls are a common health concern facing older people. An estimated one-third of older people aged ˃65 years who
live in the community, half of older people aged ˃65 years who live in residential aged care facilities (RACFs), and
half of older people aged ˃80 years in both the community and RACFs will fall each year. 2 Falls are more prevalent in
people with dementia, especially those with Parkinson’s dementia (refer to Part A. Dementia). Almost half of those
who experience a fall will have a repeat fall within the next year. Injuries are higher due to the prevalence of
underlying disease and reduced physiological reserve in older people. It is important to ask patients if they have
experienced ‘near falls’ as well as falls.
A significant proportion of falls (40–60%) leads to injury, and a further 10–15% leads to serious injury, which may
include hip fracture. Hip fracture has a significantly associated mortality rate – 10% die within a month, 20% within six
months and 33% within a year.2 Only a small number of older patients (~20%) regain full mobility after a fall.

Older people who fall are at risk of a ‘long lie’ because of the inability to get up from the fall without assistance, which
can result in hypothermia, bronchopneumonia, dehydration, pressure injuries, rhabdomyolysis and, in some
instances, death.
Falls are associated with a loss of confidence, functional decline, social withdrawal, anxiety and depression (refer to
Part A. Mental health), increased use of medical services, and a fear of falling. An older person is at greater risk of
institutionalisation following a fall.

Pathophysiology
Most falls are due to multiple interactions between an individual with a propensity to fall and other mediating
factors. 3,4 A recent Cochrane Review has found that a multi-component intervention may not be better than exercise
alone for older people living in the community. 5 However, it is widely acknowledged that there is a wide range of
contributing factors to prevent falls, and a multi-component intervention may be necessary when appropriate.

Intrinsic factors
• Advanced age
• Central processing problems
– Cognitive impairment
– Vascular dementia and Lewy body dementia (greater risk due to gait disturbance)
– Depression
• Neuromotor
– Gait and balance disturbance
– Parkinson’s disease
– Parkinson-like syndromes (eg progressive supranuclear palsy, multiple system atrophy, Lewy body
dementia)
– Stroke
– Neuropathy
– Muscle weakness
 RACGP aged care clinical guide (Silver Book) Part A. Falls 3

• Musculoskeletal
– Chronic pain (refer to Part A. Pain)
– Arthritis
– Proximal myopathy (eg hypothyroidism)
• Vision impairment
– Poor visual acuity
– Poor depth perception
– Poor contrast sensitivity
– Need for rapid adjustment to vision, bifocal or multifocal lenses
• Cardiovascular
– Orthostatic hypotension
– Neurocardiogenic syncope
– Arrhythmias
– Valvular heart disease
• Other
– Undernourishment
– History of falls
– Age – ≥80 years are particularly at risk
– Female sex
– Urinary incontinence (refer to Part A. Urinary incontinence)
– Fear of falling

Extrinsic factors
• Inappropriate footwear
• Inappropriate clothing
• Physical and/or chemical restraint (refer to Part A. Behavioural and psychological symptoms of dementia)
• Cluttered environment
• Poorly lit environment
• Alcohol use
• Household pets
• Taking more than three medications (refer to Part A. Medication management), particularly
– benzodiazepines
– neuroleptics
– antihypertensives
– antidepressants
– anticholinergics
– Class 1A antiarrhythmic medications
– hypoglycaemics.
4 RACGP aged care clinical guide (Silver Book) Part A. Falls

In practice
Investigations
Office tests to assess falls risk
There are several office tests that can be used to assist in determining the risk of falls. If available, a physiotherapist,
who will not only determine risk, but will also very often provide important diagnostic information, may be the best to
undertake a thorough gait and balance assessment. Options for office tests include:

• observing the patient’s gait

• Romberg test
• ‘timed up and go’ test
• single-leg stance
• sternal push
• shoulder tug test
• tandem gait or heel–toe walking
• functional reach
• ability to multitask
– Walk and talk: Does the person need to stop walking to engage in conversation?
– Perform simple arithmetic while walking: Does gait speed slow significantly?

Gait
• A good review of gait abnormalities is available through the Stanford University website.
• Observe postural stability, steppage, stride length and sway.
• Check for
– broad-based gait and small steps
– reduced arm swing
– stooped posture
– reduced flexion of hip and knees
– uncertainty or stiffness with turning.

Romberg test
• The Romberg test is a test of proprioception.
• A positive test is caused by proprioceptive dysfunction or vestibular dysfunction. 6
• It is positive when the patient can stand with their feet together and eyes open without losing their balance, but is
unable to remain steady with their eyes closed.
• This happens because the patient is using vision to compensate for the lack of sensory feedback they are
receiving from their lower extremities.
• A functional correlate of this might be when a person cannot close their eyes while showering.
• Most patients with cerebellar lesions cannot maintain posture with visual cues.6

Timed up and go
• The patient begins seated.
• The patient is instructed to stand from the chair and walk three metres, turn around, return to chair and sit down.
• Normally, a patient can manage this within 10 seconds.
• The timing is not as important as the observation of sitting-to-stand, gait, turning and how the person manages
the task.
 RACGP aged care clinical guide (Silver Book) Part A. Falls 5

Single-leg stance

• Observe the patient standing on one leg on a firm surface with their eyes open for 10 seconds, and repeat this
assessment two more times.
– Score 1: Complete three trials successfully.
– Score 2: Complete one or two trials successfully.
– Score 3: Unable to complete any trials.
– A score of 2 or 3 indicates significant sensory and strength impairment.

Sternal push

• This test evaluates the ability of the patient to respond to an external stress.
• The patient stands with their feet comfortably together and the examiner delivers a push to the sternum.
• Normally, a patient can recover from this by invoking postural support muscles.
• A patient who needs to take a few steps backward to adjust is at risk of falls.
• A patient who appears to make no adjustment and fall backwards is at high risk.
• This test should be carefully administered with staff placed to catch the patient.

Shoulder tug

• The patient stands with feet comfortably close together and eyes open.
• The examiner stands behind the patient, provides a warning, and delivers a brief tug backward to both shoulders.
• If the patient falls, they will fall into the arms of the examiner.
• Failing this test means the patient is at risk of falls.

Tandem gait or heel–toe walking

• The patient is asked to walk in a straight line placing one foot immediately in front of the other, heel to toe
• This requires the patient to walk with a narrow support base.
• This test can uncover cerebellar, brain stem and cerebellar tract disorders.

Functional reach

• The ability of the patient to reach in any direction outside of their base of support is important for independent
domestic living.
• A standardised version of this test is available; however, simple observation of the patient’s ability to reach
objects can be very informative.

Referral to physiotherapy

It may be prudent to refer the patient to a physiotherapist for a more detailed assessment of gait, which can identify
the source of many gait problems.
6 RACGP aged care clinical guide (Silver Book) Part A. Falls

Pathology
Depending on the various examination findings, the following investigations may be relevant:

• Full blood count

• Urea, creatinine, electrolytes
• Magnesium, calcium
• Hemoglobin A1c (HbA1c)
• Thyroid function tests
• Liver function tests
• Vitamin B12, folate
• Electrocardiography
• Echocardiogram
• Vitamin D
• Tilt testing
• Imaging

Diagnostic considerations
There are several important specific conditions to consider with falls:3,7,8,9,10,11

• Neurological conditions
– Cervical myelopathy
– Peripheral neuropathy
– Lumbar stenosis
– Cerebellar ataxia
– Parkinson’s disease and related syndromes
– Dementia
• Cardiovascular
– Vasovagal syndrome
– Orthostatic hypotension
– Carotid sinus hypersensitivity
– Cardiac rhythm disturbances
• Vestibular
– Vestibular disease
– Cervical vertigo: osteoarthritis of the neck
 RACGP aged care clinical guide (Silver Book) Part A. Falls 7

Management
The overall management of older people who regularly fall, or who are at risk of falls is illustrated in Figure 1.

Figure 1. General management approach to falls in older people

Non-pharmacological

Prevention of falls

• Postural hypotension – encourage adequate hydration, liberalise salt in diet where possible, review medications
(see below), consider graduated light pressure stockings (if tolerated), suggest small frequent meals rather than
large meals, advise mindful, slow postural adjustments after rising in the morning, after meals and after
defecation. 12,13, 14,15
• Address undernutrition.
• Manage incontinence.
• Manage visual impairment – optometrist/ophthalmologist input, expedite necessary cataract surgery. 16
• Manage hearing impairment – refer for audiology assessment.
• Develop individualised exercise program to improve muscle strength, balance, endurance and flexibility – referral
to a physiotherapist for individual or group classes may assist with improving muscle strength, balance,
endurance and flexibility.16
• Suggest commencement of Tai Chi – evidence supports role in fall prevention.16
• Refer to physiotherapist for mobility assisting devices.
• Refer to podiatrist for foot care and appropriate footwear. 17
• Refer to occupational therapist for home assessment5 and environmental modifications (eg flooring, furniture,
lighting, handrails).
8 RACGP aged care clinical guide (Silver Book) Part A. Falls

Reduction of injury in the event of a fall

• There is marginal evidence that wearing hip protector pads prevents injury in frail older people in RACFs (who are
compliant wearers).
• Environmental modifications can be made (eg carpet increases the risk of falls).

Pharmacological

Prevention of falls

• Deprescribe where possible, including a pharmacist review of medications where appropriate (refer to Part A.
Deprescribing).
• Reduce or cease psychotropic medications.
• Review medications with dehydrating effect/contributing to postural hypotension (eg diuretics, laxatives).
• Ensure the patient is replete of vitamin D by checking the baseline and supplement if required – vitamin D in
individuals with low levels may make no difference to the risk of falling but reduces rate of falling. 18
• Ensure the patient is replete of vitamin B12.
• Manage other medical conditions (as required).

Reduction of injury in the event of a fall

• Manage osteoporosis to improve bone integrity.

• Encourage vitamin D and calcium supplements (as required).

Post-fall assessment
After an older person has experienced a fall, it is important to conduct a post-fall assessment to identify any injuries,
understand what may have caused the fall and, importantly, prevent or reduce the risk of further falls. This should
include the following steps:16

• Obtain a history of the fall, mechanism, medications, acute/chronic medical conditions, and mobility levels.
• Identify sites of injury, consider the need for head injury observations.
• Has the fall resulted in a significant period of immobility? If so, close monitoring/investigation is required.
• Examine the patient, considering vision, gait and balance, and lower extremity joint function.
• Undertake a basic neurological examination: mental status, muscle strength, lower extremity peripheral nerves,
proprioception, reflexes, test of cortical, extrapyramidal and cerebellar function, and cranial nerves.
• Check basic cardiovascular status: heart rate and rhythm, postural pulse and blood pressure; if appropriate, heart
rate and blood pressure responses to carotid sinus stimulation.
 RACGP aged care clinical guide (Silver Book) Part A. Falls 9

References
1. World Health Organization. Violence and injury prevention – Falls. Geneva: WHO, 2018. Available at
www.who.int/violence_injury_prevention/other_injury/falls/en [Accessed 8 August 2019].

2. Thain J, Masud T. Prevalence of falls and injuries. In: Conroy S, Harper A, Gosney M, eds. Oxford desk reference – Geriatric medicine.
Oxford: Oxford University Press 2012; p. 424–25.

3. Kenny R, Romero-Ortuno R, Cogan L. Falls. Medicine 2013;41(1):24–28.

4. Masud T, Thain J. Aetiology of falls. In: Conroy S, Harper A, Gosney M, eds. Oxford desk reference – Geriatric medicine. Oxford:
Oxford University Press 2013; p. 426.

5. Hopewell S, Adedire O, Copsey BJ, et al. Multifactorial and multiple component interventions for preventing falls in older people living in
the community. Cochrane Database Syst Rev 2018;7:CD012221.

6. Dennis M, Bowen W, Cho L. Romberg's Test. In: Dennis M, Bowen W, Cho L. Mechanisms of clinical signs. Chatswood Australia:
Churchill Livingstone Elsevier, 2012; p. 387.

7. Victorian Geriatric Medicine Training Program. Falls and balance. Melbourne: AGMTP, 2013. Available at
www.anzsgm.org/vgmtp/Mobility [Accessed 8 August 2019].

8. Treml J. Investigation of falls. In: Conroy S, Harper A, Gosney M, eds. Oxford desk reference – Geriatric medicine. Oxford: Oxford
University Press, 2013.

9. Waldron N, Hill AM, Barker A. Falls prevention in older adults – Assessment and management. Aust Fam Physician 2012;41(12):930–
35.

10. Harris P, Garcia M. To fall is human: Falls, gait, and balance in older adults. In: Lindquist L, ed. New directions in geriatric medicine.
Switzerland: Springer International Publishing, 2016; p. 71–90.

11. Kane R, Ouslander J, Resnick B, Malonne M. Falls. In: Kane R, Ouslander J, Resnick B, Malonne M, eds. Essentials of clinical
geriatrics. 8th edn. New York: McGraw-Hill, 2018.

12. Fedorowski A, Melander O. Syndromes of orthostatic intolerance: A hidden danger. J Intern Med 2013;273(4):322.

13. Shibao C, Lipsitz LA, Biaggioni I. ASH position paper: Evaluation and treatment of orthostatic hypotension. J Clin Hypertens (Greenwich)
2013;15(3):147–53.

14. Shannon JR, Diedrich A, Biaggioni I, et al. Water drinking as a treatment for orthostatic syndromes. Am J Med 2002;112(5):355.

15. Young TM, Mathias CJ. The effects of water ingestion on orthostatic hypotension in two groups of chronic autonomic failure: Multiple
system atrophy and pure autonomic failure. J Neurol Neurosurg Psychiatry 2004;75(12):1737.

16. Gillespie L, Robertson M, Gillespie W, et al. Interventions for preventing falls in older people living in the community. London: Cochrane,
2012. Available at www.cochrane.org/CD007146/MUSKINJ_interventions-for-preventing-falls-in-older-people-living-in-the-community
[Accessed 8 August 2019].

17. Wylie G, Torrens C, Campbell P, et al. Podiatry interventions to prevent falls in older people: A systematic review and meta-analysis.
Age Ageing 2019;48(3):327–36.

18. Cameron ID, Dyer SM, Panagoda CE, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane
Database Syst Rev 2018;9:CD005465.
 RACGP aged care clinical
guide (Silver Book)
5th edition
Part A. Frailty

General principles
• Frailty is best assessed annually using a validated measurement tool.

• Prescribe appropriate physical activity that includes a resistance training component.

• Screen all patients admitted to residential aged care facilities for the risk of malnutrition.

• Early involvement of a physiotherapist can be helpful.

• Early involvement of a dietitian or nutritionist can be helpful.

• Reduction in polypharmacy can be helpful.

• Engagement of a dentist can be helpful.

• Engagement of a speech therapist can be helpful when necessary for swallowing difficulties.

• Consider comorbidities that may be contributing (eg depression, cognitive impairment).

Practice points
Practice points References Grade
Consider assessing frailty annually using one of two broad models 20 Consensus-based
– frailty phenotype model and frailty index recommendation
Avoid iatrogenic harm by having early discussion about end-of-life 24 Consensus-based
goals and appropriate limitation of invasive therapies recommendation
Be vigilant and recognise complications of acute illness that are 24 Consensus-based
common in frailty recommendation
Consider pharmacological and non-pharmacological strategies for 29, 30, 33 Consensus-based
the prevention of frailty and reduction of injury in the event of frailty recommendation
2 RACGP aged care clinical guide (Silver Book) Part A. Frailty

Vitamin D supplements to maintain normal levels may be helpful for 30 Consensus-based

older people found to be deficient in vitamin D recommendation
All patients admitted to a residential aged care facility should be 30 Consensus-based
screened for risk of malnutrition and, if at risk, referred to a dietitian recommendation

Introduction
Frailty is a syndrome of physiological decline that occurs in later life, and is associated with vulnerability to adverse
health outcomes. 1 Older people who are frail are less resilient to stressors (eg acute illness, trauma) and at an
increased risk of adverse outcomes, procedural complications, falls, institutionalisation, disability and death. 2 Old age
alone does not define frailty, and frailty is not an inevitable consequence of ageing.

Clinical context
Factors associated with increased frailty include:

• older age 3

• current smoker3

• lower educational level3

• current use of post-menopausal therapy3

• not being married 4

• depression 5

• intellectual disability 6

• being of Aboriginal and/or Torres Strait Islander descent 7

• sedentary lifestyle

• undernutrition

• chronic disease

• multimorbidity

• obesity (may contribute due to pro-inflammatory state). 8,9

Pathophysiology
There is increasing evidence that dysregulated immune, endocrine, stress and energy response systems are
important to the development of frailty. The basis of this dysregulation most likely relates to molecular changes
associated with ageing, genetics and specific disease states, leading to physiological impairments and clinical frailty.
Sarcopenia, or age-related loss of skeletal muscle and muscle strength, is a key component of frailty. Decline in
skeletal muscle function and mass are consequences of age-related hormonal changes and changes in inflammatory
pathways, including increase in inflammatory cytokines. 10 Ageing people lose height and lean body mass, but gain
and redistribute fat.
 RACGP aged care clinical guide (Silver Book) Part A. Frailty 3

Endocrine
Table 1 shows the many age-related hormone changes that have been associated with frailty. 11

Table 1. Age-related hormone changes associated with frailty

Hormone Level Comment

Growth hormone Decrease

IGF-1 Decrease

Dehydroepiandrosterone sulfate Decrease Plays a direct role in maintaining

(DHEA-S) muscle mass and prevents the
activation of inflammatory pathways
that contribute to muscle decline
Cortisol Increase May impact on skeletal muscle and
immune system
Sex steroids Decrease Evidence is mixed that lower levels
of reproductive hormones contribute
to frailty
25(OH) vitamin D Decrease

Inflammation and the immune system

There is a consistent and strong correlation between frailty and biomarkers of the innate immune system:

• Levels of pro-inflammatory interleukin (IL)-6 and C-reactive protein (CRP) are elevated in older adults.
– IL-6 adversely affects skeletal muscle, appetite, adaptive immune system function and cognition, 12 and
contributes to anaemia. 13

• There is an association between frailty and clotting markers (factor VIII, fibrinogen and D-dimer). 14

• Frail older adults are less likely to mount an adequate immune response to influenza vaccination. 15

Stress responses and metabolic systems

The likelihood and extent of frailty increases as abnormal physiological processes accumulate:

• Older age leads to dysregulation of the autonomic nervous system. 16,17

• Age-related changes in the renin-angiotensin system and in mitochondria likely impact on sarcopenia and
inflammation, both important components of frailty. 18

Undernutrition
Undernutrition is associated with a deficiency of energy, protein and other nutrients, resulting in weight loss and
changes in body composition; it may be difficult to assess in patients with fluid retention (eg ascites, oedema) and
those who are overweight. 19

Undernutrition results in:19

• reduced muscle strength

• impairment of immune function and wound healing

• slowed recovery from illness and surgery

• impaired psychosocial functioning

• poorer clinical outcomes (increased mortality, longer hospital stays, increased readmission rates).

Patients at risk of malnutrition include those with:

4 RACGP aged care clinical guide (Silver Book) Part A. Frailty

• chronic disease (eg dementia, chronic obstructive pulmonary disease, cancer, gastrointestinal, kidney or liver
disease)

• acute illness, if food is not consumed for a day or more (consider patients who are fasting for a procedure and
post-surgery)

• immobility

• frailty

• depression (refer to Part A. Mental health)

• social issues (eg low socioeconomic status, social isolation, inability to cook or shop).

In practice
Diagnosis
Consider assessing frailty annually. There are many instruments available, and two broad models of frailty have been
described: 20

• Frailty phenotype model – hypothesised to have an underlying biological basis.

• Frailty index – cumulative deficit model.

The most commonly used tool for the phenotypic frailty is the Physical Frailty Phenotype, also known as the Fried or
Hopkins tool. 21 Instruments to assess frailty include:

• Fried frailty indicators – frailty (three or more of the below), pre-frailty (one or two of the below) and not frail (none
of the below) 22
– Unintentional weight loss (≥4 kg in the past year)
– Self-reported exhaustion
– Weakness (reduced grip strength)
– Slow gait speed
– Low physical activity

• Frailty index – based on the accumulation of illnesses, functional deficits, cognitive decline and social
circumstances, it involves answering >20 medical and functional questions 23

• Clinical Frailty Scale – helpful scale that takes very little time

• Edmonton Frail Scale1

• other useful simple tests with variable specificity and sensitivity 24

– Slow walking speed (>5 seconds to walk 4 m)
– Timed up and go test (>10 seconds to stand from a chair, walk 3 m, turn around, walk back to the chair and sit
down again).
All patients admitted to a residential aged care facility (RACF) should be screened for risk of malnutrition and, if at
risk, referred to a dietitian. 25 The following tools are useful in screening for malnutrition:

• Malnutrition Screening Tool (MST) 26

• Malnutrition Universal Screening Tool (MUST) 27

• Mini Nutritional Assessment – short-form (MNA-SF) 28

• Subjective Global Assessment (SGA).29 This includes a physical assessment of lean body mass and fat mass;
useful for patients with fluid retention (eg ascites, oedema) in whom body mass index (BMI) may not reflect
nutritional status. To be completed by an accredited dietitian. 29
 RACGP aged care clinical guide (Silver Book) Part A. Frailty 5

Management

General approach24
• Early discussions should be had about end-of-life goals and appropriate limitation of invasive therapies to avoid
iatrogenic harm (refer to Part A. Palliative and end-of-life care).

• Early involvement of other health professionals, including

– physiotherapist
– nutritionist or dietitian
– dentist
– speech therapist, when appropriate.

• Vigilance and early recognition and intervention of complications of acute illness that are common in frailty, such
as
– delirium (refer to Part A. Behavioural and psychological symptoms of dementia)
– pressure injuries (refer to Part A. Dermatology)
– falls (refer to Part A. Falls).

Non-pharmacological

Physical frailty
Interventions with some efficacy in the treatment of frailty include: 30

• exercise (resistance and aerobic) – consider early involvement of a physiotherapist, if possible 31,32

• caloric and protein support31,32

• vitamin D supplements in those found to be deficient25

• reduction in polypharmacy.32

Weight loss
• Assess executive function – does the patient have capacity to plan and prepare meals?

• Is there dependency on others to eat?

• Are there difficulties with chewing and swallowing, difficulties with feeding (eg tremor)?

• Could medication side effects be a possible contributing factor?

• Is depression present?

• Are there unnecessary dietary restrictions in place (eg low salt, low fat), which make food less satisfying?

• Are financial difficulties present? (May affect quality and quantity of food intake.)

Undernutrition and malnutrition

The management of undernutrition and malnutrition depends on the degree of malnutrition. Document the patient’s
nutrition status and level of risk, agree to goals of nutrition support with the patient and/or carers, and monitor the
intervention. An accredited dietitian is best placed to provide advice on the nutrition support required.
Consider nutrition support for older people who are malnourished; for example, those with:

• unintentional loss of >10% of body weight in the past three to six months

• a BMI <20 kg/m2 and unintentional loss of >5% of body weight in the past three to six months.
Remember that not all involuntary weight loss is due to reduced food intake.
6 RACGP aged care clinical guide (Silver Book) Part A. Frailty

Consider nutritional support for older people who are at risk of malnutrition; for example, those who:

• have eaten little or nothing for more than five days, or are likely to eat little for the next five or more days (eg
elective surgery)

• are very old (consider nutrition support earlier)

• have poor absorptive capacity, nutrient losses or increased nutritional needs.

Vitamin D supplements have been found to assist in slowing the progress of physical frailty. 33, 34 Oral nutritional
supplements between meals may be helpful (if first-line strategies fail) in adding protein and calories to diet. 35 The
American Geriatrics Society’s Choosing Wisely initiative advises against the use of high-calorie supplements
because of a lack of evidence, and recommends the following strategies: 36

• Review medications

• Optimise social supports

• Provide appealing food and feeding assistance

• Clarify patient goals and expectations

• Consider removal of dietary restrictions to improve palatability of food

Pharmacological

Physical frailty
Interventions with some efficacy in the treatment of frailty include:30

• vitamin D supplements

• reduction in polypharmacy (refer to Part A. Polypharmacy).

Medication review
• Medications should be reviewed, and medications not required discontinued with care (refer to Part A.
Deprescribing).

• Consider dose reduction in frail older people.

• Adjust doses for patients with renal impairment and hypoalbuminemia.

• Review anticholinergic load – Beers Criteria. 37 Anticholinergic load is associated with voiding difficulties, cognitive
decline and reduced performance on instrumental activities of daily living. 38

• Refer to Part A. Medication management for more information.

Weight loss
If the patient has comorbid depression, consider using mirtazapine (may increase appetite and support weight gain)
or a selective serotonin reuptake inhibitor (SSRI) or serotonin-noradrenaline reuptake inhibitor (SNRI) not associated
with anorexia (eg citalopram, venlafaxine). There is no evidence to support use of antidepressants for weight gain in
a patient without depression.

Appetite stimulants
Not currently recommended in Australia and advised against in the US.36

Osteoporosis
Refer to Part A. Osteoporosis for more information.

Testosterone
Older men (aged ≥65 years) have lower testosterone levels. In men who are ageing, a lower testosterone
concentration predicts poorer health outcomes (eg frailty, cardiovascular events, mortality). However, randomised
controlled trials have not found evidence that testosterone therapy improves cardiovascular and mortality outcomes.
Supplementation in the older adult frail population is debatable, and guidelines recommend testosterone therapy for
hypogonadal men only, after careful risk–benefit assessment. 39
 RACGP aged care clinical guide (Silver Book) Part A. Frailty 7

Depression
The choice of treatment for patients with intact cognition will depend upon the severity, type, and chronicity of the
depressive episode with antidepressants and/or psychotherapy; 40,41 however, the evidence for use in patients with
dementia is less robust (refer to Part A. Dementia).

References
1. Wryko Z. Frailty at the front door. Clin Med (Lond) 2015;15(4):377–81.

2. Clegg A, Young J, Lliffe S, Rikkert MO, Rockwood K. Frailty in older people. Lancet 381(9868):752–62. Available at
www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)62167-9/fulltext [Accessed 9 August 2019].

3. Fugate Woods N, LaCroix AZ, Gray SL, et al. Frailty: Emergence and consequences in women aged 65 and older in the Women's
Health Initiative Observational Study. J Am Geriatr Soc 2005;53(8):1321–30.

4. Cawthon PM, Marshall LM, Michael Y, et al. Frailty in older men: Prevalence, progression, and relationship with mortality. J Am
Geriatr Soc 2007;55(8):1216–23.

5. Lakey SL, LaCroix AZ, Gray SL, et al. Antidepressant use, depressive symptoms, and incident frailty in women aged 65 and older
from the Women's Health Initiative Observational Study. J Am Geriatr Soc 2012;60(5):854–61.

6. Evenhuis HM, Hermans H, Hilgenkamp TI, Bastiaanse LP, Echteld MA. Frailty and disability in older adults with intellectual disabilities:
Results from the healthy ageing and intellectual disability study. J Am Geriatr Soc 2012;60(5):934–38.

7. Hyde Z, Flicker L, Smith K, et al. Prevalence and incidence of frailty in Aboriginal Australians, and associations with mortality and
disability. Maturitas 2016;87:89–94.

8. Peralta M, Ramos M, Lipert A, Martins J, Marques A. Prevalence and trends of overweight and obesity in older adults from 10
European countries from 2005 to 2013. Scand J Public Health 2018;46(5):522–29.

9. Samper-Ternent R, Al Snih S. Obesity in older adults: Epidemiology and implications for disability and disease. Rev Clin Gerontol
2012;22(1):10–34.

10. Schapp LA, Pluijm SMF, Deeg DJH, et al. Higher inflammatory marker levels in older persons: Associations with 5-year change in
muscle mass and muscle strength. J Gerontol A Biol Sci Med Sci 2009; 64A(11):1183–89.

11. Puts MT, Visser M, Twisk JW, Deeg DL, Lips P. Endocrine and inflammatory markers as predictors of frailty. Clin Endocrinol (Oxf)
2005;63(4):403–11.

12. Ershler WB, Keller ET. Age-associated increased interleukin-6 gene expression, late-life diseases, and frailty. Annu Rev Med
2000;51:245–70.

13. Ershler WB. Biological interactions of aging and anemia: A focus on cytokines. J Am Geriatr Soc 2003;51(3 Suppl):S18–21.

14. Walson J, McBurnie MA, Newman A, et al. Frailty and activation of the inflammation and coagulation systems with and without clinical
comorbidities: Results from the Cardiovascular Health Study. Arch Intern Med 2002;162(20):2333–41.

15. Yao X, Hamilton RG, Weng NP, et al. Frailty is associated with impairment of vaccine-induced antibody response and increase in
post-vaccination influenza infection in community-dwelling older adults. Vaccine 2011;29(31):5015–21.

16. Varadhan R, Chaves PH, Lipsitz LA, et al. Frailty and impaired cardiac autonomic control: New insights from principal components
aggregation of traditional heart rate variability indices. J Gerontol A Biol Sci Med Sci 2009;64(6):682–87.

17. Ogliari G, Mahinrad S, Stott DJ, et al. Resting heart rate, heart rate variability and functional decline in old age. CMAJ
2015;187(15)E442–49.

18. Burks TN, Andres-Mateos E, Marx R, et al. Losartan restores skeletal muscle remodeling and protects against disuse atrophy in
sarcopenia. Sci Transl Med 2011;3(82):82ra37.

19. Gastrointestinal Expert Group. Gastrointestinal. Melbourne: Therapeutic Guidelines, 2018.

20. Walston JD, Bandeen-Roche K. Frailty: A tale of two concepts. BMC Medicine 2015;13:185.

21. Buta BJ, Walston JD, Godino JG, et al. Frailty assessment instruments: Systematic characterization of the uses and contexts of
highly-cited instruments. Ageing Res Rev 2016;26:53–61.

22. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci
2001;56(3):M146–56.

23. Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J Gerontol A Biol Sci Med Sci 2007;62(7):722–27.

24. Turner G, Clegg A, British Geriatrics Society; Age UK; Royal College of General Practitioners. Best practice guidelines for the
management of frailty: A British Geriatrics Society, Age UK and Royal College of General Practitioners report. Age Ageing
2014;43(6):744–47.

25. Dent E, Lien C, Lim WS, et al. The Asia-Pacific clinical practice guidelines for the management of frailty. J Am Med Dir Assoc
2017;18(7):564–75.

26. Ferguson M, Capra S, Bauer J, Banks M. Development of a valid and reliable malnutrition screening tool for adult acute hospital
patients. Nutrition 1999;15(6):458–64.
8 RACGP aged care clinical guide (Silver Book) Part A. Frailty

27. Malnutrition Advisory Group. The 'MUST' Explanatory Booklet. Redditch, Worcestershire: MAG, 2003. Available at
https://bapen.org.uk/pdfs/must/must_explan.pdf [Accessed 9 August 2019].

28. Rubenstein LZ, Harker JO, Salvà A, Guigoz Y, Vellas B. Screening for undernutrition in geriatric practice: Developing the short-form
mini-nutritional assessment (MNA-SF). J Gerontol A Biol Sci Med Sci 2001;56(6):M366–72.

29. Detsky AS, McLaughlin JR, Baker JP, et al. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr
1987;11(1):8–13.

30. Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: A call to action. J Am Med Dir Assoc 2013;14(6):392–97.

31. Travers J, Romero-Ortuno R, Bailey J, Cooney MT. Delaying and reversing frailty: A systematic review of primary care interventions.
Br J Gen Pract 2019;69 (678):e61–69.

32. Ofori-Asenso R, Chin KL, Mazidi, M, et al. Global incidence of frailty and prefrailty among community-dwelling older adults: A
systematic review and metanalysis. JAMA network Open 2019;2(8):e198398.

33. Montero-Odasso M, Duque G. Vitamin D in the aging musculoskeletal system: An authentic strength preserving hormone. Mol Aspects
Med 2005;26(3):203.

34. Ensrud KE, Blackwell TL, Cauley JA, et al. Circulating 25-hydroxyvitamin D levels and frailty in older men: The osteoporotic fractures
in men study. J Am Geriatr Soc 2011;59(1):101.

35. Milne AC, Potter J, Vivanti A, Avenell A. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane
Database Syst Rev 2009;(2):CD003288.

36. American Geriatrics Society. Choosing Wisely: Ten things clinicians and patients should question. Philadelphia: AGS, 2015. Available
at www.choosingwisely.org/societies/american-geriatrics-society [Accessed 9 August 2019].

37. American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2019 updated Beers Criteria for
potentially inappropriate medication use in older adults. J Am Geriatr Soc 2019. doi: 10.1111/jgs.15767. [Epub ahead of print].

38. Han L, Agostini JV, Allore HG. Cumulative anticholinergic exposure is associated with poor memory and executive function in older
men. J Am Geriatr Soc 2008;56(12):2203–10.

39. Ali S, Garcia JM. Sarcopenia, cachexia and aging: Diagnosis, mechanisms and therapeutic options – A mini-review. Gerontology
2014;60(4):294–305.

40. Nelson JC, Delucchi KL, Schneider LS. Moderators of outcome in late-life depression: A patient-level meta-analysis. Am J Psychiatry
2013;170(6):651–59.

41. Areán PA, Cook BL. Psychotherapy and combined psychotherapy/pharmacotherapy for late life depression. Biol Psychiatry
2002;52(3):293.
 RACGP aged care clinical
guide (Silver Book)
5th edition
Part A. Urinary incontinence

General principles
• Urinary incontinence is common in older people and has an effect on multiple life domains.

• It is important to understand the different urinary incontinence subtypes, as the causative factor and
management approaches to each may be different. These subtypes may overlap in some instances, which
could complicate the clinical picture.

• A stepwise approach to urinary incontinence includes taking a detailed history, physical examination,
relevant investigations, reviewing medications and ruling out potentially reversible factors.

• A multidisciplinary approach to urinary incontinence management should be in line with the patient’s goals
and preferences. This may include lifestyle and behavioural advice (Level of Evidence: 1), consideration of
medication trials if appropriate (Level of Evidence: 3), containment or bladder drainage strategies and
possible referrals for further investigations or specialist reviews if appropriate.

Practice points
Practice points References Grade
Step 1. Evaluation
Evaluate the patient’s lower urinary tract and general medical, 5 Consensus-based
functional and cognitive status recommendation
Identify and treat transient, potentially reversible causes of 5 Grade of
incontinence using the DIPPERS mnemonic Recommendation: B

Step 2. Take a detailed history 7 Consensus-based

recommendation
Step 3. Review medication Consensus-based
Review medications that may cause or aggravate urinary 7 recommendation
incontinence
2 RACGP aged care clinical guide (Silver Book) Part A. Urinary incontinence

Step 4. Focused examination

Use validated, evidence-based frailty screening tool 6 Consensus-based
recommendation
Consider the effect of physical disability and possible cognitive 6 Consensus-based
impairment recommendation
Conduct abdominal, gynaecological, rectal, perineal skin and 6 Consensus-based
lower-limb neurological examinations recommendation
Step 5. Basic investigations
Consider including urinalysis +/– microscopy and culture as part of 6 Grade of
the basic investigation Recommendation: C
Consider including bladder chart over three days as part of the 6 Consensus-based
basic investigation recommendation
Consider including portable bladder scan for measurement of 9 Consensus-based
post-void residual urine as part of the basic investigation recommendation
Establish goals of care for urinary incontinence by taking into 6 Consensus-based
consideration patient factors, personal preference and the recommendation
capabilities of care providers
Consider altering lifestyle and behavioural measures; however, it 7 Consensus-based
may not be practical to implement many of these lifestyle and recommendation
behavioural measures for older people who have significant
cognitive impairment and/or physical disability
Consider medications, bladder drainage options and surgical 11, 12 Consensus-based
treatment options in some patients recommendation
Consider referral to specialist care based on indications for referral, 1 Consensus-based
availability, patient transport and patient preference recommendation

Introduction
Incontinence is common in older people, with increasing prevalence and severity according to age. 1 Three out of four
Australians living in supported accommodation have severe incontinence and require assistance with managing
bladder or bowel control. 2
True numbers on the prevalence of incontinence are likely to be underestimated given the nature of incontinence
being underreported, underscreened and undertreated. The most recent nationwide census of incontinence from the
Australian Bureau of Statistics (ABS) in 2012 3 found a 24% increase in prevalence between 2009 and 2012 (with
incontinence defined as the need for assistance with bladder or bowel control, and/or the use of continence aids).
Approximately 5% of people aged 65–84 years experience severe incontinence, and this increases by more than five
times for those aged ≥85 years (28%).
Incontinence is associated with increased mortality and morbidity, and alters a person’s quality of life by affecting
multiple domains:

• Physical – increases risk of falls and related fractures,1 leads to incontinence-associated dermatitis

• Functional – associated with higher levels of care required

• Emotional – linked with shame, depression, social isolation and reduced quality of life3

• Financial – the estimated total expenditure of incontinence in Australia was $1.6 billion in 2008–09, with $1.3
billion spent in residential aged care facilities (RACFs). 4 Personal costs include unsubsidised incontinence
products, specialised equipment, medications and special dietary modifications

• Residential status – 87% of aged care assessment team respondents listed incontinence as a significant deciding
factor for transition to living in residential care1
Urinary incontinence is defined as ‘the complaint of any involuntary leakage of urine’. 5 It is not a physiological part of
ageing, but age-related changes in the urinary tract system leave older people more susceptible to urinary
incontinence. 6 Some of the age-related changes include:
 RACGP aged care clinical guide (Silver Book) Part A. Urinary incontinence 3

• reduced bladder capacity

• reduced sensation of filling

• increased detrusor overactivity

• decreased bladder contractile function

• increased incidence of benign prostatic obstruction in men

• decreased urethral closure pressure and circulating oestrogen in women.

Additional factors such as reduced physiological reserve, multimorbidity (refer to Part A. Multimorbidity),
polypharmacy (refer to Part A. Polypharmacy) and environmental obstacles increase this vulnerability even further.

Clinical context
The subtypes of urinary incontinence may overlap and complicate the clinical picture for the treating physician. Refer
to Appendix 1. Definitions and terminology relating to urinary incontinence for the specific definitions for the
terminology commonly used in clinical practice that relates to incontinence.

Urge incontinence
Key factors to consider:

• Involuntary loss of urine is associated with a strong urge to void.

• This is a result of detrusor overactivity.

• Common causes include medication, age-related atrophic changes, anxiety, urinary tract infections (UTIs),
prostatic hypertrophy and neurological disease.

Stress incontinence
Key factors to consider:

• Involuntary loss of urine occurs with raised intra-abdominal pressure (eg laughing, sneezing, coughing, lifting).

• This is a result of either urethral sphincter weakness or hypermobility of the urethra and its consequent failure to
close effectively.

• It occurs more commonly in patients who are overweight, have pelvic floor weakness after childbirth, or as a
complication of prostatic surgery.

Chronic retention (overflow incontinence)

Key factors to consider:

• Involuntary loss of urine is associated with an overdistended or poorly contractile bladder.

• Continuous or intermittent leakage may occur.

• It may be caused by an atonic bladder (eg neurogenic bladder) or partial obstruction of urine flow (eg
prostatomegaly, pelvic mass, faecal impaction; refer to Part A. Faecal incontinence).

Functional or behavioural incontinence

Key factors to consider:

• It occurs in otherwise continent people who are unable to reach the toilet in time or who are not cognitively able to
recognise the need to void in an appropriate place at an appropriate time.

• Common causes include mobility problems (eg arthritis, insufficient assistance, medications, Parkinson’s disease)
and cognitive or psychiatric disorders affecting recognition of the need to void (eg dementia, depression,
medications).
4 RACGP aged care clinical guide (Silver Book) Part A. Urinary incontinence

Mixed incontinence
Key factors to consider:

• Mixed incontinence is a combination of urge and stress incontinence, for example

– older women with pelvic floor weakness that leads to idiopathic detrusor overactivity
– development of urge and stress incontinence following radical prostatectomy.

In practice
Assessment
A stepwise approach to urinary incontinence includes the following five steps:
1. Evaluation
2. Taking a detailed history
3. Medication review
4. Focused examination
5. Basic investigations

Evaluation
Evaluate the lower urinary tract, and general medical, functional and cognitive status. Identify transient, potentially
reversible causes of incontinence using the DIPPERS mnemonic (refer to Box 1 for more information; Grade of
Recommendation: B).5

Box 1. DIPPERS mnemonic6

D Delirium

I Infection

P Pharmaceuticals

P Psychological

E Excess fluid

R Restricted mobility

S Stool impaction

Taking a detailed history

When taking a detailed history of an older patient who is suspected of experiencing urinary incontinence, the
following information should be obtained: 7

• Symptoms including frequency of incontinence, amount of urine loss and use of incontinence products
(eg pads), keeping in mind that the bladder alone can often be an unreliable witness of urinary incontinence.

• Fluid intake – volume and type (including caffeine and alcohol).

• Bowel frequency, stool consistency and need to strain.

• Review of medical, past surgical or obstetric history, and conditions affecting mobility or dexterity.
 RACGP aged care clinical guide (Silver Book) Part A. Urinary incontinence 5

• Psychological factors (ie cognition and mental state; refer to Part A. Mental health).

• Patient management and effect of their incontinence (eg anxiety, low self-esteem, embarrassment in social
situations, social isolation, depression, problems with hygiene).

Medication review
It is important to review medications that may cause or aggravate urinary incontinence. For example: 8

• urge incontinence may be caused/aggravated by diuretics, selective serotonin reuptake inhibitors (SSRIs),
cholinergic and anticholinesterase agents

• stress incontinence may be caused/aggravated by alpha-adrenergic blockers

• chronic urinary retention may be caused/aggravated by anticholinergic agents, verapamil, pseudoephedrine,

opioids, and many psychotropic medications

• functional incontinence may be caused/aggravated by psychotropics, analgesics.

Refer to Part A. Medication management for more information.

Focused examination
A focused examination should consider the following:6

• Does the patient appear frail? The use of a validated, evidence-based screening tool can be helpful as frailty is
associated with an increased risk of incontinence (Level of Evidence: 1; refer to Part A. Frailty).

• Consider the effects of physical disability – observe mobility and transfers.

• Consider possible cognitive impairment – briefly assess cognitive function.

• Assess the abdomen (ie enlarged bladder, pelvic masses), bearing in mind that abdominal palpation is a relatively
insensitive method of diagnosing urinary retention.

• Gynaecological examination (ie atrophic vulval or vaginal changes, prolapse, loss of urine observed at the
urethral meatus on coughing).

• Rectal examination – inspection and digital rectal examination (ie constipation/faecal impaction, prostatic
hypertrophy, anal tone, perineal sensation).

• Perineal skin examination – inspect for dermatitis or thrush.

• Lower-limb neurological examination, focusing on weakness and any upper motor neuron signs.

• Signs of conditions associated with incontinence (eg diabetes, neuropathy, cerebrovascular disease, Parkinson’s
disease, depression).

Basic investigations
Basic investigations should include the following:6

• Urinalysis +/– microscopy and culture (Grade of Recommendation: C). Asymptomatic bacteriuria in this
population is common, and general practitioners (GPs) need to be cautious about interpreting a positive culture
result in this context.

• Bladder chart over three days (as part of the Aged Care Funding Instrument Assessment), including input and
output volumes, times of voiding and fluid intake, episodes of incontinence and some estimate of the severity of
the incontinence.

• Portable bladder scan for measurement of post-void residual urine (where possible and available) 9
– Normal bladder capacity is about 500 mL with minimal residual urine post-void.
– A residual urine volume of more than 100 mL may require further investigation.
– If a portable bladder scan is not available or there is some doubt over the result, a renal tract ultrasound to
ascertain post-void residual urine should be ordered.
6 RACGP aged care clinical guide (Silver Book) Part A. Urinary incontinence

Management
Following the five assessment steps, it is important to treat causes of potentially reversible, usually transient urinary
incontinence. If this is not possible, it is then necessary to establish goals of care for urinary incontinence by taking
into consideration patient factors (eg physical disability, cognitive impairment), personal preference and the
capabilities of care providers (Figure 1).

Figure 1. Achieving continence

Many regional aged-care service providers offer a specialised continence service with access to a geriatrician, nurse
continence specialist and continence physiotherapist:

• Nurse continence specialists can provide advice on assessment, pelvic floor exercises and suitable choice of
continence products.

• Continence physiotherapists can assist with lifestyle advice plus education on pelvic floor exercises with or
without biofeedback or electrical stimulation.
The National Continence Helpline (1800 330 066) can provide details of these clinics and services. Governmental
subsidies such as the Continence Aids Payment Scheme (CAPS) may be available for eligible parties, although most
patients in RACFs are ineligible. 10 State and territory specific programs such as the State-wide Equipment Program
(SWEP) in Victoria may provide further financial assistance.

Lifestyle and behavioural measures

It may not be practical to implement many of these lifestyle and behavioural measures for older people who have
significant cognitive impairment and/or physical disability. For such patients, the use of incontinence products is
usually the most important aspect of management, combined with a regular toileting assistance program. If possible,
the following lifestyle and behavioural measures should be implemented:7

• Appropriate fluid intake (1.5 L/day), limit caffeine and alcohol intake.

• Minimise evening fluid intake and ensure adequate night lighting for those with nocturia.

• Avoidance or treatment of constipation (eg increase dietary fibre).

• Regular toileting habits with good posture and time for complete emptying.

• Bladder retraining for urge incontinence in patients with good cognitive function.

• Pelvic floor exercises for women with stress incontinence and overactive bladder, and men with overactive
bladder.

• Toileting assistance and prompting for regular voiding.

• Incontinence products (eg disposable pants, absorbent bedding).

• Mobility aids, bedside commode or urinal, over-toilet frame.

 RACGP aged care clinical guide (Silver Book) Part A. Urinary incontinence 7

Pharmacological
In some patients, prescribed medications may be indicated:

• Oestrogen cream for atrophic vaginitis can improve incontinence and reduce the recurrence of UTIs. 11

• Aperients, including bulking agents, osmotic laxatives, stimulant laxatives or stool softeners, and, if necessary,
suppositories or enemas for constipation (refer to Part A. Faecal incontinence).

• The role of antibiotic prophylaxis for recurrent urine infections is controversial as this may promote microbial
resistance; however, this may be worthwhile to reduce urine infections, especially if there is associated delirium or
hospitalisation. 12

• Oxybutynin is an anticholinergic agent that may help relieve overactive bladder symptoms; however, there are
concerns over its side-effect profile (ie xerostomia, constipation, worsening urinary retention, cognitive
impairment). Oxybutynin remains the only Pharmaceutical Benefits Scheme (PBS)-funded medication available
for the treatment of overactive bladder in Australia. Thus, tips on prescribing include the following
– Start at low dose of 2.5 mg orally at night, increase slowly according to response and tolerability (maximum
dose is 5 mg three times a day, but frail, older people are rarely able to tolerate this dose).
– Stop if there is no benefit after four to six weeks.
– The common complaint of dry mouth may be alleviated by switching to a trial of transdermal oxybutynin, which
is associated with less dry mouth.

• Non-PBS-funded options for overactive bladder include

– solifenacin or darifenacin
- These may have fewer anticholinergic side effects because of their targeted actions on the M3 muscarinic
receptors in the bladder smooth muscle.
- Darifenacin is said to be associated with fewer central nervous system side effects, and may be an
alternative to consider in patients with cognitive impairment.
– mirabegron
- This is a beta-3 adrenergic receptor agonist that does not have anticholinergic side effects, and is an
attractive option for the older population, especially if the patient is cognitively impaired.
- Side effects include a rise in blood pressure, and is contraindicated if there is severe uncontrolled
hypertension (ie ≥180 mmHg systolic +/– ≥110 mmHg diastolic).

• Medications for treating possible bladder outlet obstruction related to prostatic enlargement because of benign
prostatic hypertrophy include
– PBS-funded options: prazosin or dutasteride–tamsulosin
- Prazosin tends to lower blood pressure, which increases the risk of falls.
- Dutasteride with tamsulosin has become a preferred option for the geriatric cohort.
- Tamsulosin alone is funded under the Department of Veterans' Affairs and not the PBS.

Bladder drainage options

Bladder drainage options include the following:

• Condom drainage – this may be an option for men with a penile shaft of reasonable length on which to attach the
condom. Condom drainage can be particularly helpful for nocturnal incontinence, although problems such as the
condom frequently falling off limits the use of this option (consultation with a nurse continence specialist is
advised).

• Indwelling catheter (ie urethral, suprapubic) – this is only considered for urinary incontinence alone if all other
treatment options have been tried unsuccessfully. The complications of an indwelling catheter, particularly
catheter-associated UTIs, catheter bypassing and recurrent blockage, usually become more of a management
problem than the urinary incontinence itself. Therefore, indwelling catheters, as a measure to manage urinary
incontinence alone, should be avoided whenever possible. Apart from incontinence, they may be needed for
managing chronic urinary retention related to conditions such as benign prostatic hyperplasia, detrusor
acontractility or neurological (usually spinal cord pathology) causes, in order to prevent risks of hydronephrosis
and renal failure.
8 RACGP aged care clinical guide (Silver Book) Part A. Urinary incontinence

Further investigations
A renal tract ultrasound may be used to investigate:

• haematuria on urinalysis

• recurrent UTIs

• benign prostatic hypertrophy to estimate prostate size, although the degree of prostatic enlargement on
ultrasound does not necessarily reflect the degree of prostatic obstruction

• chronic retention for observation of bladder trabeculation

• upper-tract dilatation in those with lower urinary tract obstruction.

Consider the following points about urodynamics:

• This is a specialised study looking at bladder function during filling and voiding; it is usually carried out by
urologists, urogynaecologists or geriatricians working with a regional continence service.

• Urodynamics should only be considered if the results of the study will clearly influence management
(eg deciding surgical treatment).

• For most older patients, urodynamics will not normally be considered; however, for mobile, medically fit patient
who are candidates for surgery, urodynamics may be appropriate.
Referral for cystoscopy depends on the patient’s clinical circumstances (refer to Indications for specialist referral).

Surgical treatments
Surgical treatments include:

• treatment of urethral obstruction in men (eg dilation of a urethral stricture, transurethral resection of prostate)

• mid-urethral sling for stress incontinence, usually in women

• administration of intravesical botulinum toxin via cystoscopy to patients with refractory overactive bladder (either
neurogenic or idiopathic). There is a risk of urinary retention post-operatively, thus patients may need to learn to
self-catheterise prior to the procedure which, for most frail older patients, may prove challenging.

Indications for specialist referral

Consider referral to geriatrics, urology or urogynaecology services for urodynamic studies or further investigations
and management. Common indications for specialist care referral include:1

• persistent haematuria

• persistent pelvic pain

• suspected pelvic mass

• symptomatic prolapse

• suspected neurological disease

• voiding difficulty

• poor response to initial therapy

• unclear type/diagnosis of incontinence.

 RACGP aged care clinical guide (Silver Book) Part A. Urinary incontinence 9

Appendix 1. Definitions and terminology relating to

urinary incontinence
There are specific definitions for the terminology commonly used in clinical practice that relate to incontinence.5
Overactive bladder syndrome Storage symptoms of urgency with or without urgency incontinence, usually with
frequency and nocturia
Detrusor overactivity Diagnosis made on urodynamics testing confirming involuntary detrusor
contractions during the filling phase, which may be spontaneous or provoked
Nocturia Interruption of sleep one or more times at night to void (in practice, a three-day
bladder diary should be recorded and assessed)
Nocturnal polyuria >33% of the total daily urine production occurs at night in older people; >20% in
younger people
Nocturnal enuresis Involuntary loss of urine during sleep

Lower urinary tract symptoms Includes both storage (ie frequency, urgency, nocturia) and voiding symptoms
(ie hesitancy, poor stream, incomplete emptying, post-void dribbling)

References
1. Lim DS. Management of urinary incontinence in residential care. Aust Fam Physician 2016;45(7):498–502. Available at
www.racgp.org.au/afp/2016/july/management-of-urinary-incontinence-in-residential-care [Accessed 9 August 2019].

2. Shamliyan T, Wyman J, Bliss DZ, Kane RL, Wilt TJ. Prevention of urinary and fecal incontinence in adults. Rockville, Maryland:
Agency for Healthcare Research and Quality (US), 2007.

3. Australian Institute of Health and Welfare. Australia’s health 2016. Canberra: AIHW, 2016. Available at
www.aihw.gov.au/reports/australias-health/australias-health-2016/contents/chapter-3-leading-causes-of-ill-health [Accessed 9 August
2019].

4. Australian Institute of Health and Welfare. Incontinence in Australia. Canberra: AIHW, 2013. Available at
www.aihw.gov.au/reports/disability/incontinence-in-australia/contents/table-of-contents [Accessed 9 August 2019].

5. Abrams P, Cardozo L, Wagg A, Wein A. Incontinence. 6th edn. Bristol: International Continence Society, 2017. Available at
www.ics.org/education/icspublications/icibooks/6thicibook [Accessed 9 August 2019].

6. Abrams P, Cardozo L, Khoury S, Wein A. Fifth International Consultation on Incontinence. Paris: European Association of Urology,
2013. Available at www.ics.org/Publications/ICI_5/INCONTINENCE.pdf [Accessed 9 August 2019].

7. Gray L, Woodward M, Scholes R, Fonda D, Busby W. Geriatric medicine: A pocket book for doctors, nurses, other health
professionals and students. 2nd edn. Melbourne: Ausmed Publications, 2000.

8. Perrotta C, Aznar M, Mejia R, Albert X, Ng CW. Oestrogens for preventing recurrent urinary tract infection in postmenopausal women.
Washington DC: Cochrane, 2008. Available at www.cochrane.org/CD005131/RENAL_oestrogens-for-preventing-recurrent-urinary-
tract-infection-in-postmenopausal-women [Accessed 9 August 2019].

9. Queensland Health. Adult urinary obstruction, retention and bladder scanning. 2nd edn. Brisbane: Queensland Health, 2011. Available
at www.health.qld.gov.au/__data/assets/pdf_file/0021/436314/clinical-guide-continence-obstr.pdf [Accessed 9 August 2019].

10. Department of Health. CAPS eligibility. Canberra: DoH, 2018. Available at www.bladderbowel.gov.au/caps/eligibility.htm [Accessed 9
August 2019].

11. Raz R, Stamm WE. A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. N Engl J
Med 1993;329(11):753–56.

12. Dason S, Dason JT, Kapoor A. Guidelines for the diagnosis and management of recurrent urinary tract infection in women. Can Urol
Assoc J. 2011;5(5):316–22.
 RACGP aged care clinical
guide (Silver Book)
5th edition
Part A. Faecal incontinence

General principles

• Faecal incontinence is common and debilitating, but poorly assessed and managed in residential aged care
facilities

• Certain risk factors (eg age) predispose a person to faecal incontinence.

• A structured approach to history, examination and relevant investigations help to identify potential causes of
faecal incontinence.

• A common, reversible cause is constipation or faecal impaction that leads to overflow incontinence, which
can be easily identified and treated in most cases.

• Treatment plans should involve a multidisciplinary approach as much as possible, keeping in mind the
patient’s goals and preferences of care.

Practice points
Practice points References Grade
Assess the type of incontinence using an objective grading system 1 Consensus-based
(eg Bristol Stool Chart) recommendation
Include a seven-day bowel chart to provide information about 1 Grade of
frequency, timing, episodes of incontinence and stool consistency Recommendation: C
during history-taking
Examination should include a digital rectal examination, 2, 5 Consensus-based
assessment of skin integrity and primary neurological conditions recommendation
Establish a regular bowel pattern by encouraging (and assisting if 1, 2 Consensus-based
necessary) the patient to open their bowels soon after a meal, at recommendation
the same time each day
Encourage adequate dietary fibre and fluid intake 1 Fibre: Level of Evidence: 1;
2 RACGP aged care clinical guide (Silver Book) Part A. Faecal incontinence

Grade of
Recommendation: B
Fluid: Level of Evidence: 2
Promote easy access to toilet or provide a commode next to the 1, 2 Consensus-based
bed recommendation
Advise regular exercise within the context of the patient’s 1, 2 Consensus-based
comorbidities and physical abilities recommendation
Regularly review the use of laxatives, as overuse can lead to 8 Consensus-based
diarrhoea and faecal incontinence recommendation
Consider that transanal irrigation may be suitable for those with 9 Consensus-based
intact cognition and high motivation levels to comply with treatment recommendation
The mainstay of treatment of faecal incontinence is often 10 Consensus-based
containment strategies (eg pads, bed protection) recommendation

Introduction
Faecal incontinence is the involuntary loss of liquid or solid faeces 1 at an inappropriate time and/or place. Anal
incontinence includes these events as well as the involuntary loss of flatus.1

Clinical context
The prevalence of faecal incontinence is estimated to be 12–13% in older people, and up to 50% for those in
residential aged care facilities (RACFs), with a higher prevalence rate among men. 2 There are few prevalence
studies of faecal incontinence in RACFs, but a prevalence of 54% was reported in one study, and another found an
incidence of 20% during a 10-month period after admission.1
In comparison with urinary incontinence (refer to Part A. Urinary incontinence), all the challenges of underreporting
and undertreating are magnified in faecal incontinence. There is a low rate of referral to primary care physicians
and/or nurse continence specialists for further assessment, with a tendency toward containment only (eg use of pads
without further evaluation). Older people themselves are often reluctant to volunteer symptoms of faecal incontinence
for social or cultural reasons. They may also be reluctant due to a popular misperception that the condition is part of
the ageing process and therefore ‘nothing can be done about it’.1

Only half of geriatricians in one study reported screening for faecal incontinence, and only a third believed that
RACFs provide good care for faecal incontinence.1 A standardised approach for screening with the help of validated
tools (eg Revised Faecal Incontinence Scale) 3 may help with early and accurate identification of faecal incontinence.
Changes in ageing (eg reduction in sphincter tone at rest, squeeze) make older people more susceptible to faecal
incontinence. Other associated risk factors include female gender, co-existing urinary incontinence, high body mass
index (BMI), loose stool consistency and prior colorectal surgery.1

Common causes
Common causes of faecal incontinence in older people include: 4

• faecal impaction – this may result from chronic constipation associated with immobility, delayed response to the
urge to defecate, decreased fluid and fibre intake or the use of certain medications (eg opioids, anticholinergics)

• reduced bowel emptying secondary to defaecatory dysfunction – poor defaecation technique due to inadequate
external sphincter relaxation and/or insufficient expulsive effort leads to retention of stool in the rectum and often
passive faecal incontinence post attempted defaecation

• neurogenic incontinence – higher central nervous system damage from severe stroke or advanced dementia
(however, mild or even moderate dementia is not a cause of faecal incontinence itself), and other neurological
conditions (eg autonomic neuropathy or spinal cord disease). The faecal incontinence associated with these
conditions is usually the result of a combination of the direct neurological insult and functional causes

• anal sphincter or pelvic muscle weakness (eg obstetric trauma, prior surgery)
 RACGP aged care clinical guide (Silver Book) Part A. Faecal incontinence 3

• loose bowel motions – diarrhoeal illness, change in dietary habits, medications (eg antibiotics, laxatives)

• colorectal disease (eg carcinoma, villous polyps, rectal prolapse, inflammatory bowel conditions or haemorrhoids)

• functional causes – secondary to either severe cognitive impairment, physical disability affecting ability to reach
toilet quickly, reduced dexterity impeding the ability to disrobe appropriately, poor toilet access, among others

• others – causes amenable to surgical intervention in younger patients (eg anal sphincter tears) are rarely the sole
cause of faecal incontinence in frail older patients.

In practice
Assessment
There are three steps in the assessment of faecal incontinence:

• History

• Examination

• Investigations

History
History-taking is an important component of assessing faecal incontinence, and should include assessing:1

• type of incontinence (eg solid, liquid or gas)

– Bristol Stool Chart (Figure 1) provides an objective grading system.
– Include a seven-day bowel chart to provide information about frequency, timing, episodes of incontinence and
stool consistency (Grade of Recommendation: C).
– Loose bowel motions can be seen in faecal incontinence because of diarrhoea or ‘overflow incontinence’
secondary to constipation.

• frequency of bowel actions and usual bowel habit

– Urgency is closely associated with diarrhoeal illness, or any cause of loose bowel motions.
– Constant passive leakage is more characteristic of overflow incontinence because of faecal impaction or
faecal incontinence because of impaired rectal emptying secondary to defaecatory dysfunction.

• timing of bowel actions

– Incontinence from severe dementia may result in postprandial bowel actions because of the gastrocolic reflex
(stool consistency often normal).

• associated symptoms

• constipation, pain or straining, local symptoms (eg rectal bleeding)

• effect on lifestyle (eg avoiding going out) and hygiene (personal and domestic)

• dietary history and appetite, including intake of fruit and fibre

• comorbidities, past history and medications (including use of laxatives and enemas)

• cognitive status, mobility, visual acuity, manual dexterity, access to toilet and carer assistance.
4 RACGP aged care clinical guide (Silver Book) Part A. Faecal incontinence

Figure 1. Bristol Stool Chart

Reproduced with permission from Waterham M, Kaufman J, Gibb S. Childhood constipation. Aust Fam Physician 2017;46(12):908–12.

Examination
After taking the patient’s history, an examination should be conducted, including:2,5

• digital rectal examination, to exclude faecal impaction or rectal mass, and assess anal sphincter tone (ie resting
and squeeze pressure), rectal prolapse and pelvic muscle tone

• assessment of anal sphincter and pelvic muscle tone may be difficult or impossible in older people with cognitive
impairment or in those who are unable to squeeze on demand. Reduced anal sphincter tone can occur with long-
standing constipation – this is due to continued activation of the recto-anal inhibitory reflex, anal sphincter
damage (eg post-childbirth) and lower spinal cord or cauda equina lesions (the latter would also usually be
associated with reduced perineal sensation)

• assessment of skin integrity is important given faecal incontinence can lead to the development of dermatitis or
pressure ulcers, especially in those with impaired mobility1

• primary neurological assessment, although not a common cause of faecal incontinence, primary neurological
conditions such as spinal cord injury should be considered, and a lower-limb neurological examination should be
conducted along with testing perineal sensation, and observing for the anal reflex (contraction of the external anal
sphincter upon stroking perianal skin or ‘anal wink’).

Investigation
Investigations are not necessary in all cases, but can be useful for more severe cases of faecal incontinence,
especially if the cause is not clear. This could include:2

• a plain abdominal X-ray to exclude faecal loading, although interpretation of lesser degrees of faecal loading is
subjective

• stool microscopy, culture and sensitivity, including testing for Clostridium difficile toxin for persistent or severe
diarrhoea if there is no other clear cause for the faecal incontinence
 RACGP aged care clinical guide (Silver Book) Part A. Faecal incontinence 5

• a colonoscopy to rule out sinister pathology; however, in the RACF context, a holistic view needs to be adopted to
ensure benefits outweigh risks, and decisions are made in line with the patient’s values, preferences and long-
term prognosis
– features that suggest underlying malignancy include change in bowel habit, appetite and weight loss,
anaemia, rectal pain or bleeding and faecal incontinence.

• screening for malabsorption syndromes (eg lactose intolerance, gluten sensitivity, fat-malabsorption,
carbohydrate malabsorption) in selected older people only, especially if there appears to be a relation to diet.

Management
The management and treatment of faecal incontinence depends on the underlying cause. Multiple interventions may
be required and, ideally, a multidisciplinary approach is advised where simple measures have been ineffective.
However, there is currently limited high-quality evidence in this setting to guide management.

Faecal incontinence in RACFs is commonly due to constipation with colonic loading and overflow. Thus, efforts to
prevent this should be part of the care plan for all residents. Behavioural and non-pharmacological measures include
the following:1,2

• Try to stimulate the patient’s usual bowel pattern and establish a regular bowel pattern by encouraging (and
assisting if necessary) the patient to open their bowels soon after a meal, at the same time each day. Stool transit
can also be stimulated by appropriately trained professionals with abdominal massage in the direction of colonic
transit.

• Encourage adequate dietary fibre (Level of Evidence: 1; Grade of Recommendation: B) and fluid intake (Level of
Evidence: 2; plus consider dietitian referral).

• Promote optimisation of toilet access or provide a commode next to the bed.

• Advise regular exercise within the context of the patient’s comorbidities and physical abilities.
Regular prompted toileting and structured exercise programs administered separately have not been found to reduce
faecal incontinence. However, the combination of both in one randomised controlled trial found a reduction in faecal
incontinence, albeit with the need for increased staff-to-resident ratios in RACFs (1:5), challenging the feasibility of
these interventions in everyday clinical practice. 6
Simple patient and carer education on proper bowel habits includes the following points: 7

• Respond promptly on urge to defaecate.

• Provide privacy to defaecate wherever feasibly possible.

• Adjust/modify position of toilet to facilitate rectal evacuation (eg back support, footstool to achieve squat position).

• Engage in regular exercise to promote bowel actions.

Bulking agents (eg psyllium found in oats, cereals, commercial preparations) may help reduce the incidence of faecal
incontinence, although these should not be given to older people who are frail with poor oral intake as constipation
can be worsened.

Medications to treat constipation include: 8

• stool softeners (eg docusate)

• osmotic laxatives

• stimulants (eg senna, bisacodyl) may work better than other agents for those with poor oral intake or fluid
restrictions

• suppositories (ie glycerine, bisacodyl or microenema [eg docusate 5 mL]), generally for more severe constipation
where the patient is unresponsive to other laxatives. This should be used according to response, but usually
these are only required second or third daily.
All laxatives need to be regularly reviewed as overuse can lead to diarrhoea and faecal incontinence.
Transanal irrigation may be suitable for those with intact cognition and high motivation levels to comply with
treatment. It can reduce the severity of constipation and incontinence, improve quality of life and promote
independence. 9 It requires nurse continence specialists to provide patient and carer support via training and
education.

For severe constipation with impaction, consider the following:

6 RACGP aged care clinical guide (Silver Book) Part A. Faecal incontinence

• If a rectal examination shows the patient is rectally impacted, suppositories or a microenema should be
administered, with a result expected within 30–60 minutes.

• If the rectal examination does not confirm rectal impaction, but the patient has not opened their bowels for some
days +/– the abdominal X-ray showed faecal loading, oral macrogol can be given (up to eight sachets over a six-
hour period for not longer than three days).

• Occasionally, impaction may require manual evacuation with premedication for pain if the faecal impaction has
not been responsive to the above measures, although this is not commonly needed.
For faecal incontinence related to persistent diarrhoea, not clearly due to an infectious cause (eg acute
gastroenteritis, C. difficile), loperamide can be used in an attempt to reduce the frequency of faecal incontinence.
However, infection and other causes should be excluded prior to regular use. Rare adverse cardiac events have
been reported with loperamide (although usually with higher doses), and it may also lead to constipation, especially if
taken regularly.8
The treatment of faecal incontinence associated with neurological conditions (eg cerebrovascular disease,
Parkinson’s disease) follows the same principles outlined above. Patients with spinal cord disease often have faecal
incontinence associated with constipation, which is therefore the primary management target. Management principles
such as a regular toileting program and non-pharmacological measures are also applicable in this patient group. A
common laxative regime used in patients with spinal cord disease includes docusate and senna (given separately) in
the evening, followed by glycerine +/– bisacodyl suppositories after breakfast in the morning. Anal stimulation may
also be required to facilitate relaxation of the anal sphincter. Management can often be difficult and should be guided
by specialist advice wherever possible.
Pelvic floor muscle retraining has few adverse effects; however, there is little evidence for its effectiveness in frail,
disabled older people. It is also rarely practical in the residential care setting because of patient factors (eg cognitive
impairment) and lack of resources to instruct in the technique and to monitor progress.
Containment strategies are often the mainstay of treatment, and include pads and bed protection. Anal plugs can be
effective for achieving control of faecal incontinence in certain cases; however, these are often poorly tolerated. Input
from nurse continence specialists can be invaluable in determining the best containment methods. Governmental
subsidies such as the Continence Aids Payment Scheme (CAPS) may be available for eligible parties, although most
patients in RACFs are ineligible. 10 State and territory specific programs such as the State-wide Equipment Program
(SWEP) in Victoria may provide further financial assistance.
Skin care is crucial in the management of incontinence, and includes: 11

• regular checks to ensure the skin is clean and dry

• washing skin with soap-free cleanser or soap alternative

• regular pad changes

• application of barrier cream.

A small minority of patients with troublesome faecal incontinence that is unresponsive to conservative measures who
are willing, and are medically fit, to undergo invasive testing and surgical intervention can be referred for specialised
investigations to assess for surgical treatments. These can include surgical sphincter repair or considerations of other
strategies such as peri-anal bulking agents, sacral neuromodulation or percutaneous tibial nerve stimulation.5
Many regional aged-care service providers offer a specialised continence service with access to a geriatrician, nurse
continence specialist and continence physiotherapist. The National Continence Helpline (1800 330 066) can provide
details of these clinics and services.
 RACGP aged care clinical guide (Silver Book) Part A. Faecal incontinence 7

References
1. Abrams P, Cardozo L, Wagg A, Wein A. Incontinence. 6th edn. Bristol: International Continence Society, 2017. Available at
www.ics.org/education/icspublications/icibooks/6thicibook [Accessed 9 August 2019].

2. Guinane J, Crone R. Management of faecal incontinence in residential aged care. Aust J Gen Pract 2018;47(1–2):40–42. Available at
www1.racgp.org.au/ajgp/2018/january-february/management-of-faecal-incontinence [Accessed 9 August 2019].

3. University of Wollongong. Tools for assessing and monitoring faecal incontinence: The revised Faecal Incontinence Scale (RFIS).
Wollongong: UoW, 2012. Available at http://anzctr.org.au/AnzctrAttachments/372846-RFISBrochure.pdf [Accessed 9 August 2019].

4. Gray L, Woodward M, Scholes R, Fonda D, Busby W. Geriatric medicine: A pocket book for doctors, nurses, other health
professionals and students. 2nd edn. Melbourne: Ausmed Publications, 2000.

5. Abrams P, Cardozo L, Khoury S, Wein A. Fifth International Consultation on Incontinence. Paris: European Association of Urology,
2013. Available at www.ics.org/Publications/ICI_5/INCONTINENCE.pdf [Accessed 9 August 2019].

6. Schnelle JF, Alessi CA, Simmons SF, Al-Samarrai NR, Beck JC, Ouslander JG. Translating clinical research into practice: A
randomized controlled trial of exercise and incontinence care with nursing home residents. J Am Geriatr Soc 2002;50(9):1476–83.

7. Reuban DB, Herr KA, Pacala JT, et al. Geriatrics at your fingertips. 7th edn. New York: The American Geriatrics Society, 2005.

8. Australian Medicines Handbook. AMH aged care companion. Adelaide: Australian Medicines Handbook, 2018.

9. National Institute for Health and Care Excellence. Peristeen transanal irrigation system for managing bowel dysfunction. London:
NICE, 2018. Available at www.nice.org.uk/guidance/MTG36/chapter/1-Recommendations [Accessed 9 August 2019].

10. Department of Health. CAPS eligibility. Canberra: DoH, 2018. Available at www.bladderbowel.gov.au/caps/eligibility.htm [Accessed 9
August 2019].

11. Continence Foundation of Australia. Skin care. Surrey Hills, Vic: CFA, 2019. Available at www.continence.org.au/pages/skin-care.html
[Accessed 9 August 2019].